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Running head: TRANSITIONAL CARE PLAN1Transitional Care PlanNameInstitution Affiliation
TRANSITIONAL CARE PLAN2Transitional Care PlanPatient Rebecca Snyder along with relatives and social laborer, was interviewed for theadmitting demographics. Rebecca Snyder is a woman of 56 years of age with a long term obeseOrthodox. Snyder has a past medical history of poorly controlled diabetes, hypertension,hypercholesterolemia, anxiety, and obesity. She admits to the ED with protests of hyperglycemiamore than 230 for more than ten days, frequent urination, mild abdominal discomfort, malaise,and dyspnea on exertion. As per the medical records, on date 5th August 2019, the patient wasdetermined to have Ovarian Cancer, and she was under medication for the condition. Therefore,the paper aims to explore medical information and outline the nursing care plan for RebeccaSnyder.Snyder’s Case on Transitional Care PlanHealthcare is advancing, and there has been a push to give care in the community ratherthan protracted hospitalizations. These advances require a safe, effective, and ideal care plan forthe patient and the family. Naylor et al. (2017) state that transitional care alludes to thecoordination and congruity of medical care while developing a patient starting with onehealthcare setting, then onto the next healthcare setting or the patient's home. Transitional careincludes the careful coordination and planning of the multidisciplinary group to guarantee asmooth change for the patient and the family (DelBaccio et al., 2015). Drawing in and teachingthe patient and family concerning the patient's complex healthcare needs and the requirement fortransitional care require a multidisciplinary team to keep away from disarray and superfluousreadmissions.
TRANSITIONAL CARE PLAN3Key Elements and Information Needed for Transitional CareThe Joint Commission(2015) recognizes the seven basics of the Transitional Care Model(TCM) as essential in ensuring a safe transition from a healthcare facility to another. Thefollowing are the seven approaches to enhance Snyder’s effective transitional care plan;1. Leadership support: With the hospital, home health agencies senior leaderships, andnational policymakersbecoming more conversant with the challenge of the transition, they havebecome invested in finding solutions and the initiatives to be valuable in reducing readmissionsand achieving other favorable outcomes.2. Multidisciplinary collaboration: For safe transition, the multidisciplinary arrangementneeds to commence the care, not just before the transition, and it also consists of involvement bythe patient and family/friend caregivers, as well as healthcare professionals, and moreimportantly, the social workers(SW) and nurse case managers(CM) (Labson, 2015).

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Term
Fall
Professor
MATHENGE
Tags
Health care provider, transitional care, Rebecca Snyder

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