The Transition of Care from A Hospital to A Skilled Nursing Facility

The Transition of Care from A Hospital to A Skilled Nursing Facility

Identify your selected example of a transition of care.

Transition care includes the care given to the patient or a client when they are moved from one setting to another. The different settings where transition care is applicable include assisted living facilities, nursing homes, a hospital, and or even a primary care physicians. In the transition of care from a hospital, a qualified nurse must establish whether the patient is stable enough to be moved from the hospital to another facility where the care would be provided. The paper will focus on the patient’s transition of care from a hospital to a skilled nursing facility. The care provided at the hospital is closely related to the care that a patient or client might receive in a skilled nursing facility because the personnel is well trained in improving the quality of life.

Caramanica et al. (2019) posit that the transition from a hospital setting implies that many changes will occur, including the change in the physical setting, the kind of care the patient will receive, and the interactions in the new setting. Even though the transitions are important and meant to enhance the treatment or recovery of the patient’s health, the processes can be expensive and lead to lapses in the health and safety of the patient. It is apparent that there are errors that might happen during the period, including miscommunications on the medication and care that the patient is supposed to get. There are also instances where the patient might not be well satisfied with the care level they will receive in the new facility. In most cases, the hospital care is acute for patients, and the reduction of the same might have an impact on the patient; to avoid this, the level of care at the skilled nursing facility must be level that of the hospital setting.

Describe the key stakeholders involved in this transition of care and the leadership strategies you would use to engage and influence them.

In the process of transition of care from the hospital to a skilled nursing facility, some key stakeholders are involved. Naylor et al. (2017) highlight that various needs arise during this period and thus need the right personnel to help address any issues that might arise in the process. The main stakeholder in the process is the nurse practitioner. Nurses are taking with compiling pans meant to facilitate the transition care by having in place the important patient information and instructions for the nursing facility on how the care should be done. These are the details that a lead nurse must share with the new care team to seamlessly hand over the patient to the new nursing facility. A nurse also interacts with all the stakeholders involved, including the client’s family members, to obtain critical information that could help in a successful transition of care. The information could also help identify and eliminate any communication barriers in the process (Naylor et al., 2017). The lead nurse might also make follow-ups with the skilled facility staff on the progress of the patient and be available for consultations on patient care when the need arises.

The second class of stakeholders in the transition of care from a hospital to a nursing facility is the client’s family. They include the individuals directly involved in the patient’s caregiving or providing any form of assistance to the patient. At the time of sickness, patients, especially the older ones or those with a terminal illness, might find it a challenge to manage various tasks by themselves. It includes taking medications. The families are mainly involved in the transition of care by providing important information to the lead nurse and the nursing facility where the care is transitioned (Enderlin et al., 2013). The lead nurse has a role in encouraging open and progressive communication between the nurses and the family to equip the family members with the right information on taking care of the patient. The family also participates in making critical decisions and managing any medical complexity that may arise.

The other stakeholder in the transition of care is the care manager at the skilled nursing facility, which is the next care setting after the hospital. These are trained medical professionals tasked with providing care services to the patients once they are transferred from a hospital setting. They can be trained nurses, therapists, and even pathologists. Their main role in the transition of care is to work toward patient recovery, guided by the information handed over to them by the hospital nurses (Caramanica et al., 2019). The personnel here might help continue the services being provided for the patient by the nurses in the hospital setting. They must closely follow the guidelines from the previous setting and communicate with the family members on the progress of the patient and in making any major decisions on patient care.

Explain how you, as a nurse leader and your healthcare team, would apply systems thinking when providing a transition of care aligned with the IHI Quadruple Aim framework to improve it. Explain the fourth aim and strategy you would use and why.

Every nurse works towards ensuring that patients’ lives are improved through providing quality health care. The IHI Quadruple Aim framework stipulates that a nurse towards improving the health of a population, reducing the cost of care, ensuring that the patient experience of healthcare is enhanced, and improving provider satisfaction (Stiefel and Nolan, 2012). As a nurse, I will apply the IHI Quadruple Aim framework to improve the outcomes of my care provision. There are various strategies that I would put in place to ensure that I have achieved the objectives stipulated by the framework. I would aim to motivate my team through documentation. It would enhance a smooth flow of work and also motivate the employees. One of the ways is to offer a competitive salary and other forms of remuneration to the employees. It would help ensure turnover is minimal and that they are motivated enough to work alone without much supervision.

The fourth aim includes the work-life balance that is important in enhancing the healthcare provision while allowing the healthcare team to have a better balance in their life. It is a way of attaining joy at work. The second strategy that would prove to be effective is the expansion of the roles of the team members to allow the nurses and medical assistants to help with preventive care satisfaction (Stiefel and Nolan, 2012). The strategy must align with the right amount of time that the team is supposed to work to avoid burnout. Ensuring that only trained staff are involved in demanding responsibilities effectively enhances the quality of healthcare. As a lead nurse, my team has to be motivated well and well geared towards providing the best form of care to the patients. Using the fourth aim effectively would make the work easy and enjoyable for me as the lead nurse and the team.

Explain how systems thinking would inform your improvement plan for the specific transition of care you selected.

System thinking is effective in various fields and plays major roles in healthcare, including providing patient-centered care, helping solve problems, and creating room for questioning. System thinking enhances the understanding of the various relationships and interactions in the transition of care from the hospital to a skilled nursing facility (Leslie et al., 2018). As a health policy maker and practitioner, the aspect would greatly guide the right interventions that would help provide quality health care to the patient. It would also help understand the impact of the interventions and the consequences that might arise from the change. I would effectively apply these aspects when making an improvement plan by considering how the patient will benefit from the interventions in the new facility.

The system thinking processes that would prove to be quite important include observing the structure, processes, and results of the same. By considering the available resources, the lead nurse can understand how accessible and available they are. On the part of processes, it would be important to consider the team’s service delivery to the patient in the transition period (Leslie et al., 2018). The result represents the general outcomes accrued from the care provision at the transition time. The patient’s satisfaction represents one of the main factors determining the outcomes. Other factors include the improvement of the health status of the patient and the mortality rate, which would indicate how successful the care is. The sigma model can be applied to improve the quality of healthcare, in this case, to help prevent any medical errors, especially those related to prescription and administration.


Caramanica, L, Bressler, T., Betz, C. L., Zalon, M. L., Shelton, D., Chlan, L. L., … Arsianian-Engoren, C. (2019). A concept analysis of transitions of care for population health. Research & Theory for Nursing Practice, 33(3), 257–274.

Enderlin, C. A., Mcleskey, N., Rooker, J. L., Steinhauser, C., Davolio, D., Gusewelle, R., & Ennen, K. A. (2013). Review current conceptual models and frameworks to guide transitions of care in older adults. Geriatric Nursing, 34(1), 47–52.

Leslie, H. H., Hirschhorn, L. R., Marchant, T., Doubova, S. V., Gureje, O., & Kruk, M. E. (2018). Health systems thinking: A new generation of research to improve healthcare quality. Plus Medicine, 15(10).

Naylor, M. D., Shaid, E. C., Gass, B., Levine, C., Li, J., Malley, A., McCauley, K., … Williams, M. V. (2017). Components of comprehensive transitional care. Journal of American Geriatric Society, 65(6), 1119–1125. doi:10.1111/jgs.14782

Rochester-Eyeguokan, C. D., Pincus, K. J., Patel, R. S., & Reitz, S. J. (2016). The current landscape of transitions of care practice models: A scoping review. Pharmacotherapy, 36(1), 117–133. DOI: 10.1002/phar.1685

Stiefel, M., & Nolan, K. (2012) A guide to measuring the triple aim: Population health, experience of care, and per capita cost. [IHI Innovation Series white paper] Cambridge, MA: Institute for Healthcare Improvement. Retrieved from