Nursing 475R Assignment: Transition of care to the community setting Transition of care is moving care from one location or level to the next level. Which may include transition from acute care to extended care, rehabilitation and to the patients home. Many health facilities have made the investment of a coordinator for this transition of care. The role of this individual is to assist the patient to have a safe and effective transition of care that will meet the individual patients needs. The role is similar in institutions, but the name for the role varies. Some of the common names for this role are; discharge planner, discharge coordinator, discharge nurse, nurse navigator, case manager, patient care facilitator, and transition team coordinator. Directions: Find an individual in your immediate or larger community that meets this description. Schedule a phone or in person interview with the RN to discuss their role in transitioning patients to their home after acute and or rehabilitation stays. Possible questions to ask during interview. What is your role at this facility? Who else is on the discharge team that you collaborate with? Population of patients that you assist? What are some of the resources you find for the patients in the community setting? How do you feel your role assists the patient to remain in their home or the community? What are some of the biggest challenges that you have encountered? What about dealing with some of the more vulnerable populations, what difficulties do you encounter? (homeless population, immigrants, poverty, LGTBQ population, veterans, prisoners, mental illness, minorities, non-English speaking) Find two supporting references either written or on line. Discuss from the references and the interview what you have learned about discharge planning that will help you in your current position or a position that you would like to have in the future. In a word document of minimum of 2 pages and maximum of 4 pages the information from the resources and from the interview what you have learned about discharge planning that will help you in your current position or a position that you would like to have in the future. Include the answers to the questions that you have asked during your interview. Reference your sources. Upload this under assignment tab: Transition of Care to the Community Rubric for the transition of care document (total of 35 points) 1. Introduction (9 points) Define the role of discharge planner, case management, or care facilitator as it relates to your interviewee. Define one of these roles as per the resources Use of these roles within health care today from the resources 2. Summary of the interview (20 points) How they define their role Some of the common issues that are encountered How they help patients return to their communities and or their own homes Barriers experienced by the discharge planner/case manager Resources within the community settings Other information obtained during the interview 3.Reflect on what you have learned from this experience and how you might use it in your current position or one in the future. (3 points) 4. List your references per APA format (3 points)
