System of Transition of Care Essay.

Posted: November 22nd, 2022

System of Transition of Care Essay.

The World Health Organization (2016) emphasizes the importance of a system of transition of care because “transitions from one care setting to the next are often accompanied by changes in health status.” A healthcare leader must have a plan in place to make these transitions as smooth as possible. Feeley (2017) reminds nurse leaders that patients are the main focus of the Quadruple Aim, so you must prepare for change with this in mind.System of Transition of Care Essay.


This Assignment focuses on your leadership goal of keeping patients at the forefront of any change, including transitions.


Feeley, D. (2017, November 28). The triple aim or the quadruple aim? Four points to help set your strategy [Blog post]. Institute for Healthcare Improvement. Retrieved from

World Health Organization. (2016). Transitions of care: Technical series on safer primary care. Retrieved from;jsessionid=18835745F81D91E258BFF7B409AF48D1?sequence=1

To prepare:System of Transition of Care Essay.

Review feedback on your Week 4 Assignment. You should incorporate your Instructor’s feedback and continue to add to and refine your annotated bibliography for your selected transition of care.
Consider the nurse leader’s role in achieving the IHI Quadruple Aim for this transition of care. (Hint: Draw from resources on systems thinking and nurse leaders’ ability to influence innovation and change.)System of Transition of Care Essay.

Assignment (5–6 pages, not including title and reference page):

Write a paper in which you address the following:

Identity your selected example of a transition of care.

Describe the key stakeholders that might be involved in this transition of care and the leadership strategies you would use to engage and influence them.System of Transition of Care Essay.

Explain how you, as a nurse leader along with your healthcare team, would apply systems thinking when providing a transition of care aligned with the IHI Quadruple Aim framework in order to improve it. Explain the fourth aim and strategy you would use and why.
Explain how systems thinking would inform your improvement plan for the specific transition of care you selected.
Be sure your paper includes a title page and a reference page. You should also resubmit your refined Annotated Bibliography.System of Transition of Care Essay.

Homebound Transition of Care From the Hospital: A Systems Approach by the Nurse Leader and Her Healthcare Team

Transition of care refers to the movement of a patient from one care setting to another. It is broader than merely transferring a patient from one part of the care setting to another part. The latter is what is usually referred to as “clinical handing over” and is narrower in meaning than transition of care. True transition of care involves removing the patient from one care setting completely and moving them to a totally different environment where they may not benefit from the services they enjoyed in the previous care setting (WHO, 2016).System of Transition of Care Essay.

Transitions of care have been recognised as a weak link in the care provision continuum. This is because if not handled well, there are always adverse patient outcomes as a result of misunderstandings and the passage of incomplete ir incorrect information. Thus transitions of care present considerable risks to the patient. Sone of these risks and unfavorable outcomes include preventable morbidity and mortality, preventable additional hospital visits, unnecessary or duplicate tests, preventable readmissions to the hospital, emotional stress for families, patients, and caregivers, and dissatisfied patients, families, and care givers with regard to continuation of care (WHO, 2016). This paper. This paper considers homebound transition care from the hospital and the role played by nurse leadership in the process.System of Transition of Care Essay.

Stakeholders in Homebound Transition of Care From the Hospital

There are several important stakeholders involved in the homebound transition of carenof a patient. Each of these has an important contribution to make to ensure that the transition is as seamless as possible and that mistakes are not made in the process to disadvantage the patient. Together, these stakeholders have the task of making the care experience for the patient memorable, even as they transition from the hospital environment to the home environment. This is the main objective of one of the three Triple Aims of the Institute for Healthcare Improvement or IHI (Feeley, 2017). According to Weaver et al. (2016), the period of hospital stays is reducing at a fast rate because of significant advances to healthcare technologies and adoption of evidence-based practice. Because of, transition of care to the home environment is becoming more and more important and therefore should be handled with sophistication. The continued recovery and improvement of the patient at home is a direct factor of the efficiency of the transition of care process. Proper and correct information given to the patient, their family, and caregivers has been positively correlated to satisfaction with transition of care coordination (Weaver et al., 2016).System of Transition of Care Essay.

Nurses are arguably the most important of the stakeholders in homebound transition of care. This is however not to say the others are less important. Zangerle et al. (2016) have opined that effective transitions of care are achieved by close collaboration between disciplines and players. As auch, nurse leaders have the difficult task of coordinating this transition of care among all the players. Being the representatives of the leadership of nurses in the hospital, nurse leaders must provide an enabling wirk environment as a leadership strategy to encourage nurses in the team to be thorough when a patient is being discharged. They should also allow for criticism of procedures without victimisation, and accept proposals and new ideas from the junior nurses. This way, they will positively influence the nurses involved in the discharge of a patient not to leave anything to chance. For instance, because of these leadership strategies, these nurses will ensure that the patient, the family, and the home caregiver understand the correct dosages of drugs to take, any adverse side effects to look out for, and the correct lifestyle changes to make amongst others.

Clinicians who are the prescribers are the other important stakeholders in homebound transition of care. They are the ones who prescribe the medications that the patient is discharged with to go home. As a nurse leader, the leadership strategies to engage clinicians and influence them include openness, firmness, and the propensity to question when in doubt. The nurse leader is the patient advocate and their role in coordinating and managing the transition of care cannot be underestimated (Zangerle et al., 2016). For instance, if the clinician were to unnecessarily prescibe an oral antibiotic on discharge, it is the role of the nurse leader to question this and ensure corrective action is taken to prevent patient developing antibiotic resistance.System of Transition of Care Essay.

The patient, their family, the pharmacist, and the home caregiver are some of the other important stakeholders that the nurse leader has to engage with amd influence. She must be friendly and approachable, and must be willing to answer all questions posed by the patient, their family, and the home caregiver. Additionally, she must always liaise with the pharmacist to clarify any grey areas and unclear instructions concerning the drugs the patient is discharged with.

Aligning Systems Thinking with the Quadruple Aim Framework in Providing Homebound Transition of Care

The Triple Aim framework of the Institute for Healthcare Improvement (IHI) involves making better the health of patients, providing a memorable care experience, and mitigating the cost of healthcare (Feeley, 2017). For the purposes of the kind of nurse leader discussed in this paper, the fourth objective included to make this a Quadruple Aim will be the creation of a conducive work environment (Feeley, 2017).System of Transition of Care Essay.

Improving the Health of Patients

The idea of the Triple aim was to place the patient’s interest at the centre of care. It is therefore patient focused, will all the stakeholder efforts directed at the wellbeing of the patient (Feeley, 2017). In order to offer a transition of care to the home environment that is patient friendly, therefore; the nurse leader and her team must invoke tenets of systems thinking. This requires the nurse leader and her team to carefully examine problems that may be identified before acting on them. They must alao ask questions all the time, in order to forestall any adverse outcomes that may occur to the patient due to negligence once discharged. As such, the nurse leader must always ask what an intervention is for, why the intervention is necessary, whether the intervention can be effectively carried out at home, how it will be carried out, and when or how frequently it should be done once the patient is at home (Goodman, 2018).System of Transition of Care Essay.

Improving the Care Experience

This is the second factor in the Triple Aim of IHI. According to systems thinking, our actions may have consequences that we may not immediately appreciate (Goodman, 2018). These may be either positive or negative. Therefore, in order not to destroy the transition of care experience for the homebound patient, the nurse leader and her transition team must observe, take stock of any patterns, and seek to understand the causes of particular outcomes. Most importantly, every team member must appreciate that no one professional can undertake the task of transition of care alone.System of Transition of Care Essay. Systems thinking is all about interprofessional collaborative communication. It also recognizes that the patient’s problems can have multiple solutions that can be provided by different team members (Goodman, 2018). All this will assist in improving the care experience of the patient and their family.

Mitigating Healthcare Costs

Zangerle et al. (2016) have pointed out that transitions of care present challenges in terms of costs and quality outcomes. As such, they aver that transitions of care must mitigate costs instead of worsening them. Mitigating healthcare costs is the third factor in IHI’s Triple Aim. In order to prevent adverse outcomes of transition of care such as preventable readmission which is costly, the nurse leader and her transition team must adopt an open-minded approach. This is what systems thinking advocates for, as it leads to multiple approaches to solving problems that arise during the process of transition (Goodman, 2018).System of Transition of Care Essay.

A Conducive Work Environment

This is the added fourth factor that tirns the Triple Aim into the Quadruple Aim (Feeley, 2017). When staff enjoy an understanding and caring work environment, they are often committed to providing exceptional care to their patients. This ahould be at the back of the nurse leader’s mond at all times. She should appreciate her nurses and other team members, and incorporate their suggestions (encourage innovation).

Systems Thinking in the Improvement of Homebound Transition of Care  

Systems thinking advocates for careful reflection before acting. It also calls for appreciation of the fact that actions have consequences and therefore multiple solutions must be readied. All these attributes of systems thinking therefore augur well with the improvement of homebound transition of care, if adopted by the transition team members. Rhe nurse leader must also practice transformative leadership that not only encourages innovation, but also clinical inquiry for evidence-based practice (Remus & Kennedy, 2012).System of Transition of Care Essay.

In conclusion, homebound transition of care is a critical moment in the care spectrum. It requires the nurse leader and her team to adopt a systems approach and incorporate the tenets of IHI’s Triple Aim.System of Transition of Care Essay.

Literature on transitions of care


Baldonado, A., Hawk, O., Ormiston, T. & Nelson, D. (2017). Transitional care management in the outpatient setting. BMJ Quality Improvement Reports, 6(1), u212974.w5206. DOI: 10.1136/bmjquality.u212974.w5206. Retrieved from

Brief summary:

Baldonado et al. (2017) is a journal article that presents the results of research study exploring the position that nurses can play in improving patient-centered outcomes, quality of care, and resource utilization as regards transitions of care for high risk high cost patients with multiple or severe health care issues. It particularly notes that this population of patients places a strain on medical resources through presenting complex medical conditions and functional limitations. In addition, the authors report that failures in the outpatient care of these patients stresses medical resources through creating a need for long-term care and supportive services. As such, there is a need for better management of transitions of care for this population across the care continuum. Given this awareness, a pilot study was conducted that engaged a transitional care manager in an outpatient setting with a focus on helping patients to smoothly transition through care, problem solving and outreach services.System of Transition of Care Essay. Besides that, the study engaged a collaborative team comprised of pharmacist, health educator, specialist, nurses and physicians who provided supportive services. The results of the study reported that patients exhibited reduced encounters with the emergency departments, from 33 encounters prior to the intervention to 17 encounters after the intervention. Also, the results reported cost saving and improved patient outcomes. The results of the study show that transitional care management can improve patient-centered outcomes, quality of care and resource utilization among high risk high cost patients with multiple or severe health care issues (Baldonado et al., 2017). Salmond and Echevarria (2017) supports these sentiments by noting that nurse leaders are positioned to leader transformative changes in the health care industry. This would occur through coordination of care across settings and provider to improve care quality and outcomes while reducing spending, particularly through preventing adverse drug interactions, multiple prescriptions, repeated medical histories, repeated diagnostic testing, and unnecessary utilization of medical facilities (Salmond & Echevarria, 2017). Overall, Baldonado et al. (2017) is useful in exploring and highlightingthe unique position that nurse leaders can play in outpatient settings as transition care managers to improve patient-centered outcomes, quality of care, and resource utilization.System of Transition of Care Essay.


The Importance of Nursing Leadership During Homebound Transition of Care From the Hospital: An Annotated Bibliography

Care transition from one care setting to another is an important milestone in all patient’s care continuum. Care transition means coordinating continuity of care from one care setting to another (Zangerle et al., 2016). Many authors and scholars agree that it is the weakest point in the process of caring for the patient. Therefore, if not managed properly, itbmay result in negative outcomes and adverse effects to the patient. These negative outcomes include unnecessary readmissions and even mortality in the worst case scenario (Fuji et al., 2012; Abrashkin et al., 2012; Werner et al., 2016). Werner et al. (2016) argue that care transitions are usually costly and effective care management is therefore crucial in reducing costs and preventing adverse outcomes like noncompliance to treatment due to misunderstanding at discharge. This paper looks at the evidence available about transition of care. It further narrows down ti transition of care fron the hospital setting to the home setting.System of Transition of Care Essay.

Annotated Bibliography

Abrashkin, K.A., Cho, H.J., Torgalkar, S., & Markoff, B. (2012). Improving transitions of care from hospital to home: What works? Mount Sinai Journal of Medicine, 79(5), 535–544. DOI: 10.1002/msj.21332

The authors in this paper try to paint the ideal scenario of effective care transition according to them. They argue, rightly, that it is the quality of the care transition that ultimately affects factors such as the patient’s compliance to treatment and their general outcome.

These authors also argue, rightly, that timely discharge summaries that are shared with the next level provider, post-discharge two-way communication, and follow up are important steps in ensuring an effective patient care transition from the hospital to the home setting. However, the authors clearly miss the point when they insist that the most important players in this care transition are physicians and pharmacists. Nurses are only mentioned in passing, as merely part of the care team. This is misleading. Nurses are the leaders and the most important link in care transitions. In fact, they are the primary contact between the provider and the patient.

Fuji, T., Abbott, A.A., & Norris, J.F. (2012). Exploring care transitions from patient, caregiver, and health-care provider perspectives. Clinical Nursing Research, 22(3), 258-274. DOI: 10.1177/1054773812465084

Fuji et al. (2012) aver that if care transitions are not well managed, negative patient outcomes like readmissions inevitably occur. They examined the nature of care transitions from the standpoint of the patient, the caregiver, and the provider. The qualitative descriptive study methodology that they used was apt. What they assessed were the perceptions of these groups of stakeholders on their role, the nature of care transition, barriers to seamless transition, and possible ways of surmounting the barriers. Among the answers they got were that it is important to plan for admissions (and discharges), and that a multidisciplinary approach is necessary to prepare patients for discharge. All these are important factors that nurse leaders must consider as yhe drivers of patient welfare during transitions to the home environment.System of Transition of Care Essay.

Weaver, F.M., Perloff, L., & Waters, T. (1999). Patients’ and caregivers’ transition from hospital to home: Needs and recommendations. Home Health Care Services Quarterly, 17(3), 27-48. DOI: 10.1300/J027v17n03_03

The authors opine that the need for effective care transition from the hospital to the home environment has become even more important. This is because hospital stay is reducing in duration, with preference being goven to continuation of care at home. Theirs was a descriptive study of hospital patients discharged to continue care at home. Data collected revealed that there was a positive correlation between satisfaction with care at home and the amount of information received from the discharging team. In this, it is instructive to note that nurse leaders have the most important role in ensuring this information on discharge is timely, accurate, and appropriate for the patient and the next of kin.System of Transition of Care Essay.

Werner, N.E., Gurses, A.P., Leff, B. & Arbaje, A.I. (2016). Improving care transitions across healthcare settings through a human factors approach. Journal for Healthcare Quality, 38(6), 328–343. Doi: 10.1097/JHQ.000000000

These authors argue that the quality of care transitions is coming into sharp focus lately. This is because preventable readmissions and other adverse outcomes are becoming more frequent, with patient and next of kin satisfaction dipping due to low quality of the transitions. They thus suggest that significant financial investment by the provider is necessary to train staff for better care transition services. These staff include the nurse leaders who are the primary contacts. They also suggest the adoption of the Human Factors and Ergonomics (HFE) systems approach that will assess the human factors that impede the success of an effective care transition model in the healthcare system.

Zangerle, C. & Kingston, M.B. (2016). Managing care coordination and transitions: The nurse leader’s role. Nurse Leader, 14(3), 171-173. DOI:10.1016/j.mnl.2016.04.002

On their part, Zangerle et al. (2016) suggest the employment in care transitions of six principes. These were formulated by nurse leaders from the American Organization of Nurse Executives (AONE) and the American Academy of Ambulatory Care Nursing (AAACN).System of Transition of Care Essay.


The fact that effective and thoughtful care transitions are crucial in discharged patients’ outcomes is not in dispute. However, there is need for nurse leaders and team members in the care transition team to step up their efforts in their role as patient educators and advocates.

System of Transition of Care Essay.


Expert paper writers are just a few clicks away

Place an order in 3 easy steps. Takes less than 5 mins.

Calculate the price of your order

You will get a personal manager and a discount.
We'll send you the first draft for approval by at
Total price:
Live Chat+1 (631)333-0101EmailWhatsApp