D117 Phase 1

D117 Phase 1

Student Name

Western Governors University

D117 Advanced Health Assessment for the Advanced Practice Nurse

Prof. Name:

Date

GoReact Video Reflection

Overview of Phase 1 Reflection

This GoReact video reflection summarizes Phase 1 of my care transition project. The primary focus of this phase was to analyze program expectations, identify factors contributing to hospital readmissions, and apply this knowledge to the development of a comprehensive discharge and transition-of-care plan. Initial exploration of a medical program website provided essential insight into program requirements and highlighted trends in hospital readmission following discharge. This foundational review emphasized the importance of structured discharge planning, patient education, and interdisciplinary coordination to improve patient outcomes and reduce preventable readmissions.

Review of the Patient Case and Clinical Background

The care transition plan was developed for a female patient diagnosed with chronic obstructive pulmonary disease (COPD) who was discharged following a four-day hospital admission for therapeutic management. The patient has a complex medical history that includes a complete hysterectomy, hypertension, osteopenia, and a 12-year history of COPD. Prior to hospital admission, the patient experienced worsening dyspnea, which resulted in the prescription of pulmonary rehabilitation. Although she received inpatient treatment from a hospitalist, several unresolved issues were identified at discharge, including difficulty with urination and limited access to her primary care provider, whose appointment availability ranged from three to five weeks.

What Challenges Were Identified During the Transition of Care?

The patient faced multiple challenges during the transition from hospital to home. These included gaps in follow-up care, delayed access to primary care services, unresolved urinary complications, and the potential for medication discrepancies. Patients with COPD are particularly vulnerable during care transitions due to the chronic and progressive nature of the disease, which increases the risk of symptom exacerbation and hospital readmission (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2024). These barriers highlighted the need for timely communication, coordinated follow-up, and patient-centered education.

Why Is Education and Communication Critical for Preventing Readmission?

Research findings clearly indicate that effective education and communication are essential components of successful recovery and readmission prevention. Patients who understand their diagnosis, medications, warning signs, and follow-up expectations are more likely to adhere to treatment plans and seek timely medical assistance (Coleman et al., 2006). For this patient, targeted education focused on recognizing respiratory distress, understanding discharge instructions, and knowing when and how to seek help was central to the care transition plan.

Care Transition Plan and Interdisciplinary Interventions

The discharge plan incorporated patient education, medication reconciliation, and social support services to address both medical and non-medical barriers to recovery. Education included instructions on symptom monitoring, use of prescribed therapies, and strategies for accessing care between scheduled appointments. Pharmacy involvement ensured accurate medication reconciliation and reduced the risk of adverse drug events, which are common during care transitions (Naylor et al., 2011). Additionally, social support services were included to assess for barriers such as transportation, financial limitations, or lack of caregiver support.

Key Components of the Care Transition Plan

How Will This Plan Benefit the Patient After Discharge?

The proposed care transition plan is designed to support the patient’s recovery at home by addressing clinical needs, enhancing self-efficacy, and ensuring continuity of care. By strengthening education, improving communication pathways, and engaging interdisciplinary resources, the plan reduces the likelihood of complications that could result in hospital readmission. This approach aligns with evidence-based transition-of-care models that emphasize patient engagement, care coordination, and proactive follow-up as essential strategies for improving outcomes in patients with chronic conditions such as COPD.

References

Coleman, E. A., Parry, C., Chalmers, S., & Min, S. J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822–1828. https://doi.org/10.1001/archinte.166.17.1822

Global Initiative for Chronic Obstructive Lung Disease. (2024). Global strategy for the diagnosis, management, and prevention of COPD. https://goldcopd.org

D117 Phase 1

Naylor, M. D., Aiken, L. H., Kurtzman, E. T., Olds, D. M., & Hirschman, K. B. (2011). The importance of transitional care in achieving health reform. Health Affairs, 30(4), 746–754. https://doi.org/10.1377/hlthaff.2011.0041