Patient Engagement in Transitional Care

The Clinical Nurse Leader Master’s project was conducted about a public health program called the Transitional Care Program that was working in partnership with a county hospital system, Santa Clara Valley Medical Center. The specific aim was to reduce hospital re-admissions of high-risk patients by supporting patient motivation and engagement in the Transitional Care Program by May 2015. Over a four-month period, data was collected through ten client visits, interviews with two public health nurses, information available about the program, and current research conducted on transitional care, hospital discharges, and patient engagement. Various aspects of the program were assessed, such as the general microsystem relationships, stakeholders involved in the program, the patient population at risk for re-admissions, and processes of the program. Findings identified weaknesses and strengths of the microsystem and challenges that decrease that ability of the program staff to prevent re-admissions into the hospital system. Evidence-based research collected highlighted communication as a pain point in transitional care practices. Focus of project development was aimed at the nurse-patient relationship in transitional care, and a communication tool was developed to engage the patient in goal development and decrease the risk of hospital re-admissions. This tool was presented to the program staff for review and approval of testing with clients. Implementation of the communication tool was used with two client cases and at the close of each case, the patient will be asked to fill out a survey about the use of the communication tool related to their transitional care experience. Evaluation data to be collected include the number of urgent care visits, goals accomplished as stated by the patient, and incidents of re-admissions to the hospital