Transition Skills Therapy Paper

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Identification of a Clinical Problem: Transition Skills Therapy The Institute of Medicine focuses on patient safety in order to promote policies and best practices that create safe and high-quality health care environments. Developing a pre-community discharge program would impact patient safety and quality of care both in the facility and post discharge for optimal safety and success in the community setting. The steps required to ensure quality of life in the community, relies heavily on a pre-discharge plan. [Here, a comma separates the subject from its verb and the rest of the sentence. This can confuse the reader by creating a false break in the idea. What can you omit to fix this?] This plan will focus on a set time frame…show more content…
Within the MFP (Money Follows the Person) program, there has been numerous research performed regarding reinstitution rates, and smaller focus on transition strategies to adequately prepare consumers for returning to the community. Current practice focuses on initiatives to transition persons in institutional settings to community-based waiver services; individuals do not have to wait for community-based services, which have long interest lists. The policies in place outline best practice of collaboration across the broad spectrum, however there is no outlined focus on preparation for success. It is the goal of this writer to develop a standardized plan of care, utilizing evidence based practice to improve patient outcomes. The purpose of this evidence-based practice immersion project will determine if implementation of a readmissions reduction program effects 90 day readmission…show more content…
Agencies have been able to identify patient characteristics associated with rehospitalizations unique to specific patient populations. High-risk patients, specifically those that are discharging from long term care facilities, require specialized interventions beyond the traditional scope of typical health care services. Targeted interventions using process-of-care analysis may result in fewer unplanned hospital admissions for transitional living patients. This immersion defines care transitions, describes health reform initiatives to systemize care transitions, explores various evidence-based care transition models, and offers practice and policy recommendations for improving care transitions. Several care transition models are considered to be evidence-based (they apply the best available research findings); however, most of these models are designed for targeted populations moving from one specific setting to another. Nonetheless, all care transition models share common
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