Poverty Inequality Dynamics

Hospital to Home Transitions

Hospital to Home Transitions

Phase 1 is the planning stage of a research project; students are to identifying a specific topic you would like to investigate and relates to transitional nursing ( YOU CAN SELECT THE TOPIC)

You will briefly introduce the situation by utilizing published nursing research articles to support your statement. This assignment will also include:

  1. Introduction to the Problem
  2. Clearly Identify the Problem
  3. Significance of the problem to Nursing
  4. Purpose of the research
  5. Research questions
  6. Master’s Essentials that aligned with your topic

REQUIREMENTS:

-3 PAGES

– APA 7TH EDITION FORMAT MANDATORY

– SCHOLARLY REFERENCES NO OLDER THAN 5 YEARS

– MUST ORIGINAL AND UNIQUE ASSIGNMENT, NO MORE THAN 10% PLAGIARISM ALLOWED.

– DUE DATE JULY 3, 2025 NO LATER

-RUBRIC ATTACHED

– PROPER GRAMMAR AND SPELLING

Hospital to Home Transitions

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APA

Hospital to Home Transitions

Introduction to the Problem

Transitional care is a critical component of nursing practice, particularly when patients move between different care settings such as from hospital to home. Poorly managed care transitions contribute to fragmented care, medication errors, unnecessary hospital readmissions, and increased healthcare costs (Naylor et al., 2020). Older adults, especially those with chronic conditions or cognitive impairments, are particularly vulnerable during transitions due to polypharmacy, limited mobility, and lack of caregiver support. Transitional nursing plays an essential role in ensuring these patients experience a safe, informed, and well-coordinated discharge process.

Clearly Identifying the Problem

Hospital-to-home transitions for older adults often suffer from insufficient discharge planning, lack of communication between providers, and poor patient understanding of discharge instructions (Calderón-Larrañaga et al., 2021). Research shows that nearly 20% of Medicare patients discharged from hospitals are readmitted within 30 days, with many cases being preventable (Centers for Medicare & Medicaid Services [CMS], 2022). A significant contributor to this issue is the absence of a structured, nurse-led follow-up protocol post-discharge. This gap not only impacts patient outcomes but also adds burden to the healthcare system. Transitional nurses, when strategically positioned, can bridge this gap through interventions such as medication reconciliation, caregiver education, and post-discharge check-ins.

Significance of the Problem to Nursing

For the nursing profession, transitional care represents a high-impact opportunity to reduce patient risk, enhance continuity, and uphold quality of care standards. Nurses are uniquely positioned to lead this process due to their ongoing engagement with patients, clinical judgment, and advocacy skills. Addressing poor transitions aligns directly with patient-centered care and quality improvement, two cornerstones of modern nursing. The American Nurses Association (ANA) emphasizes that improving care coordination and reducing avoidable hospitalizations are nursing imperatives (ANA, 2020). Thus, investigating and implementing nursing-led solutions for care transitions aligns with professional responsibilities, ethical practice, and system-level improvements.

Purpose of the Research

The purpose of this research is to examine the effectiveness of nurse-led transitional care interventions in reducing hospital readmissions among older adults. The goal is to generate evidence that supports the implementation of structured discharge education, home visits, and post-discharge phone follow-ups conducted by registered nurses or advanced practice nurses. By exploring existing models such as the Transitional Care Model (TCM) and Care Transitions Intervention (CTI), this study seeks to identify best practices and propose sustainable solutions for implementation in hospital systems.

Research Questions

  1. How do nurse-led transitional care programs affect 30-day hospital readmission rates among older adults discharged to home?

  2. What components of transitional care nursing are most effective in promoting patient understanding and adherence to discharge instructions?

  3. What are the perceived barriers and facilitators among nurses implementing transitional care models in acute care settings?

Master’s Essentials Aligned with This Topic

This topic aligns with the following Essentials from the American Association of Colleges of Nursing (AACN, 2021):

  • Essential II: Organizational and Systems Leadership – Addressing care transitions requires understanding system workflows and leading quality improvement initiatives.

  • Essential IV: Translational Scholarship for Evidence-Based Practice – The project involves applying research findings to develop evidence-based interventions that improve care continuity.

  • Essential VI: Health Policy and Advocacy – The outcomes of this research can inform discharge planning policies and advocate for nurse-led care transition programs within health systems.

Conclusion

Transitional care nursing holds the potential to transform the hospital discharge experience for older adults, leading to fewer readmissions, safer recoveries, and improved patient satisfaction. By focusing on structured, nurse-led interventions supported by research, this project seeks to contribute meaningfully to both clinical practice and healthcare policy. The investigation will also support professional growth aligned with the Master’s Essentials, preparing advanced practice nurses to be leaders in system-level transformation.

References

American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdf

American Nurses Association. (2020). Nursing: Scope and standards of practice (4th ed.). ANA.

Calderón-Larrañaga, A., Vetrano, D. L., Ferrucci, L., Mercer, S. W., Marengoni, A., Onder, G., & Johnell, K. (2021). Multimorbidity and functional impairment—bidirectional interplay, synergistic effects and common pathways. The Journals of Gerontology: Series A, 76(4), 603–611. https://doi.org/10.1093/gerona/glaa236

Centers for Medicare & Medicaid Services. (2022). Hospital Readmissions Reduction Program (HRRP). https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/hrrp/hospital-readmission-reduction-program

Naylor, M. D., Hirschman, K. B., McCauley, K. M., Pauly, M. V., & Nguyen, H. Q. (2020). The Transitional Care Model: 25 years of supporting evidence. Contemporary Nurse, 56(4), 313–326. https://doi.org/10.1080/10376178.2020.1833460

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