My goal was to help hem stay as independent as possible so they could remain in their own living environment as well as reduce hospitalizing and improve outcomes for the company worked for. Started to incorporate some of the concepts used in the Transition Theory but more specifically the work of Mary Anally and Janet Van Cleave who developed the Transitional Care Model from the University of Pennsylvania. By implementing the role of a transitional care nurse, I was able to support my patient’s with tools and information they needed to help them stay healthy enough to remain in their own home.
FAA Abraham Miles is a reorient nurse sociologist, educator, theorist, and researcher that began her nursing career in her native Egypt in the sass’s (Alligator, 2014). FAA Miles first developed Transition Theory while working on her doctorate in the mid sass’s and further developed it over the next three decades while working as a nurse educator and researcher. She conceptualized the idea of Transition Theory as it applies to nursing practice while working on her idea of role supplementation.
Her theory is described as having four types of transition- developmental, situational, health/illness, and organizational Mêlées, Sawyer, Im, Hollering-Messiahs, & Schumacher, 2000, p. 17). FAA Miles Transitions Theory is used as its theoretical basis for the University of Pennsylvania center call Transitions and Health, directed by Mary Anally (Alligator, 2014). Was first introduced to transitional care at a nursing conference attended to seek ways to improve outcomes for our chronically ill older patients and to keep them at home instead of being admitted in the hospital or nursing home.

Often times a patient who is chronically ill is admitted to the hospital over multiple episodes of care for an exacerbation of an illness along with other commodities. Once the patient is stable, they are discharged to home with a plan of care that does not reflect their needs, goals, learning style, or literacy level (Anally & Van Cleave, 2010, p. 459). Usually nobody is involved in developing the discharge plan from his family or in the teaching of new medications prescribed. There may even be possible dietary changes that need to be made by the patient.
I am sure the hospital does an exceptional job managing their acute medical episode but they do not have time to address the “root cause” of their multiple, recent hospitalizing (Anally & Van Cleave, 2010, p. 459). Most patient’s do not understand what was discussed with them while inpatient. They just want to go home and will say they understand just to be able to do just that. They may not have the means to get to the pharmacy to get their new medications or they may not be able to afford the new medication. There are so many variables that can occur and that is why a transitional nurse may be beneficial.
According to Anally & Van Cleave, the Transitional Care Model (ETC) provides comprehensive discharge planning and home follow-up care for chronically ill, high risk older adults admitted to the hospital for common deiced conditions. A transitional care nurse, who is usually master-prepared, follows patients from the hospital to their homes, providing evidence-based services aimed to meet the patient and family goals, improve health outcomes, and stop usual patterns of going to the emergency room for non- emergent needs (Anally & Van Cleave, 201 0, p. 60). The transitional care nurse focuses on increasing the patient and family ability to manage the frequent transitions in health that characterize chronic illness trajectory (Anally & Van Cleave, 2010). In relation of person, transition theory takes into inconsideration that all people are unique and will interpret their transition in different ways. The nurse must be able to assess how the patient perceives their change and develop therapeutics geared toward their perception, assessing for feedback along the way (Chick & Miles, 1986).
This can be achieved by using the Transitional Care Model as a guideline. The home care agency worked for decided that I would follow our patients with a diagnosis of congestive heart failure and/or chronic obstructive pulmonary disorder with commodities and Medicare was their primary insurance. My role as the ruinations care nurse was to be the primary coordinator of care to assure that there was continuity of care throughout the next thirty days (episode of care) and readmission would be avoided.
When a patient of ours was admitted to the hospital, I would visit the patient to do an in-hospital assessment and speak to the discharge planner to let them know what my role was once the patient was discharged. Once the patient was home, I would make home visits every week for the first two weeks and then follow- up phone calls the third and fourth week. Also was available by phone if they needed me anytime in between. My first home visit consisted of helping them fill out a personal health record which included current medications, medical conditions, emergency contacts and so forth.
This is when I would discover if they really understood what medications they were supposed to be taking and if they knew the reason why they were taking it for. Most patients had no clue why they were taking medicine for what medical condition or they were not taking the medication as prescribed by their physician because they did not think it was that important or they could not afford it. Sometimes the patient was taking the same medication but the deicing was labeled differently from different pharmacies. Ad the time to explain what each medication was and what it was used for. Was also able to resolve any medication discrepancy from the discharge instructions for the patient. We would call the physician’s office together so it gave them a sense of well-being and gave them control of their own health which is a positive outcome according to Melanie’s transition theory. The second home visit usually consisted of education regarding their diagnosis and which “red flags” to be aware of pertaining to their illnesses.
Socioeconomic status, education bevel, and cultural beliefs all affect potential health related outcomes (Mêlées et 2000). It is important as a nurse to be mindful of how to present information in a way that the patient will understand and be willing to make the changes needed to remain a healthful person. Emphasis on early identification of “red flags” and how the patient and/or family responds to the symptoms is a way to achieve positive outcomes and avoid readmission (Anally & Van Cleave, 201 0, p. 461).
Contact is made via a telephone call instead of a home visit for the third and fourth consultation. This is the time hat would answer any remaining medication questions, discuss the outcomes of their recent follow-up appointment with either their primary care physician or specialist, help them make an appointment with their physicians if they have not already done so, and reinforce when or if the patient would need to seek medical treatment. Often times, the patient and or family felt comfortable with their health goals because they were a part of making them which made them feel more accountable.
Even though would not be following up with them on a regular basis they knew they could contact me and I would help them in any way I could. While in my role as the transitional care nurse, felt I made a difference in the company by improving outcomes and patient satisfaction. It was very rewarding to be a part of the patients health experience but in a different way than I was before. I witnessed a transition or change in the patients attitude towards their health because they were made to be a part of the process not just a person with an illness who did not know anything.
Unfortunately, due to zero reimbursement from insurance companies, the transitional care nurse position was eliminated. The Transitional Care Model is a good concept but more research deeds to be done so insurance companies can see the value in such a program. Ms. Melanie’s Transition Theory has been applied to many different nursing research projects that apply to distinct populations undergoing change (Alligator, 2014). Through the nursing research that is being performed at the university of Pennsylvania where Ms.

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