Interprofessional Collaboration

Interprofessional Collaboration

Interprofessional Collaboration 150 150 Peter

Interprofessional Collaboration

Planning for our patients during times of transitions (for example: hospital to home, home to rehabilitation facility) involves collaboration with a number of healthcare professionals. Please address the following questions:

How does your facility promote interprofessional collaboration during times of patient transitions?
What is the role of the nurse in patient transitions?
What gaps can you identify in this process related to quality of care? (If you are not currently in practice, please use a previous role or clinical experience in your answers.)

Sample Paper

Interprofessional Collaboration

My current workplace promotes interprofessional collaboration during care transition through follow-up calls. The approach is applicable where the patient has a designated caregiver in their destination (a home nurse or caregiver in a rehabilitation facility). The caregivers at our facility contact the destination clinicians within twenty-four hours of transition to check how the patient is settling. If there are any challenges, they offer their opinion on what the new caregivers can do to maintain or improve the health status. Therefore, the interaction enhances the interprofessional relationship, enhancing patient outcomes.

Nurses are vital to the transition process since they design the new care plan. They collaborate with the patients and other caregivers to establish health goals and determine the available resources (Bajorek & McElroy, 2020). Using this information, they can then create a care plan that will help the patient through the next phase of care. Nurses are also the main communication conduit during the transition. They ensure that other clinicians and patients remain updated throughout the transition process.

There are various gaps in this care transition system. First, caregivers can hardly plan for is the availability of resources in the destination setting. The patients and the families may not have ready access to community health resources that would enable them to maintain their health. Consequently, the patients’ health will deteriorate and may even result in rehospitalization. Furthermore, in the hospital-to-home transition, the caregivers cannot monitor regular adherence to recommended practices. Patients may lose the motivation to change their lifestyle or take their medication per prescription, resulting in suboptimal health outcomes (Garvey et al., 2017). Hence, the follow-up is inadequate, making the transition process inefficient.

References

Bajorek. S. A., McElroy, V. (2020, Mar. 25). Discharge Planning and Transitions of Care. https://psnet.ahrq.gov/primer/discharge-planning-and-transitions-care

Garvey, K. C., Foster, N. C., Agarwal, S., DiMeglio, L. A., Anderson, B. J., Corathers, S. D., Desimone, M. E., Libman, I. M., Lyons, S. K., Peters, A. L., Raymond, J. K., & Laffel, L. M. (2017). Health Care Transition Preparation and Experiences in a U.S. National Sample of Young Adults With Type 1 Diabetes. Diabetes Care, 40(3), 317–324. https://doi.org/10.2337/dc16-1729