Transitional Care Plan Assessment 3

Complete an interactive simulation in which you will make decisions about a patient’s end-of-life care (Simulation is complete already, you will use it to write the essay). Then, develop a transitional care plan, 4–5 pages in length, for the patient.

To prepare for this assessment, recommend appropriate end-of-life care for Mrs. Snyder and see how those recommendations can affect the lives of the patient and her family.


Develop a transitional care plan for Mrs. Snyder.

Transitional Care Plan Format and Length

You may use a familiar transitional care plan format or template—for example, one used in your organization—or you may create your own. A link to an example is provided in the Suggested Resources.

  • Format your transitional care plan in APA style; an APA Style Paper Tutorial is also linked in the Suggested Resources to help you. Be sure to include:
    • A title page and reference page. An abstract is not required.
    • A running head on all pages.
    • Appropriate section headings.
  • Your plan should be 4–5 pages in length, not including the title page and references page.
Supporting Evidence

Cite 3–5 sources of scholarly or professional evidence to support your plan.

Developing the Transitional Care Plan

Note: The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your transitional care plan addresses each point, at a minimum. Read the Transitional Care Plan Scoring Guide to better understand how each criterion will be assessed.

  • Provide the key plan elements and information needed to ensure safe, high-quality transitional care and improved patient outcomes.
    • Include elements such as emergency and advance directive information, medication reconciliation, plan of care, and available community and health care resources.
  • Explain the importance of each key element of the transitional care plan.
    • Identify potential effects of incomplete or inaccurate information on patient outcomes and the quality of care.
    • Cite credible evidence to support your assessment of each element’s importance.
  • Explain the importance of effective communications with other health care and community services agencies involved in the transition.
    • Identify potential effects of ineffective communications on patient outcomes and the quality of care.
  • Identify barriers (actual or potential) to the transfer of accurate patient information from the sending organization to the ultimate patient destination.
    • Consider barriers inherent in such care settings as long-term care, sub-acute care, home care services, and home care with support.
    • Identify at least three barriers.
  • Develop a strategy for ensuring that the destination care provider has an accurate understanding of the patient medication list, plan of care, and follow-up plan.
    • Cite credible evidence to support for your strategy.
  • Write clearly and concisely, using correct grammar and mechanics.
    • Express your main points and conclusions coherently.
    • Proofread your writing to minimize errors that could distract readers and make it difficult to focus on the substance of your plan.
  • Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.
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