Transitional Individual/Family Centered-Care1



Transitional Individual/Family Centered-Care1







Engagement of Individual and/or Families in Planning and Shaping Their Health Care

“Patient activation” refers to a patient’s knowledge, skills, ability, and willingness to manage his or her own health and care. “Patient engagement” is a broader concept that combines patient activation with interventions designed to increase activation and promote positive patient behavior, such as obtaining preventive care or exercising regularly. Patient engagement is one strategy to achieve the “triple aim” of improved health outcomes, better patient care, and lower costs (James, 2013, p. 1).


Coulter (2012) reports, “Patient engagement acknowledges that patients have an important role to play in their own health care. This includes reading, understanding and acting on health information (health literacy), working together with clinicians to select appropriate treatments or management options (shared decision making), and providing feedback on health-care processes and outcomes (quality improvement).”

Strategies are focused on supporting and strengthening the individual’s determinations of their healthcare needs and self-care efforts with improved health. These strategies can attract an individual/family by focusing on their priorities and individualizing the interactions that are appropriative and comfortable (e.g., health literacy, readiness for change, accessible, affordable).

This is a very large culture change. Previously, the professional would approach health teaching with a list of what to teach and proceed to teach the contents of the list. It was concluded that the individual/family has learned. Without an understanding of the individual/family readiness or ability to learn, this “one size fits all” concludes with little understanding or motivation to change health behaviors, with a probable outcome of increased anxiety for those involved.

To engage individuals/families, health professionals focus on listening not talking, and increased question asking, to assess the specific concerns and barriers to change. The desired outcomes are increased comfort to ask questions, enhance confidence with better support, more informed, more discriminating about the effects of medical treatment, and more opportunities for participation (Coulter, 2012).

Evidence of effective engagement strategies can be (Barnsteiner, Disch, & Walton, 2014; Coulter, 2012):



  • Choosing healthier lifestyle


  • Understanding the causes of disease and behaviors to prevent onset or exacerbation of the disease


  • Self-diagnosing and treating minor conditions


  • Knowing when to seek advice and professional help



  • Choosing appropriate health-care providers


  • Accessing the appropriate care site, for example, primary care, urgent care, emergency room, and specialists


  • Coping with the effects of chronic illness and self-managing their care


  • Monitoring symptoms and treatment effects; knowing what is problematic


  • Determining their own end-of-life decisions


  • Decreased nonparticipations in health-care decisions; decreased onset or exacerbations of disorders and related care costs

Refer to Appendix D Strategies to Promote Engagement of Individual/Families for Healthier Outcomes in varied health-care settings, for example, primary/specialty care, acute care, long term.


Discharge versus Transition

In the last 5 years, hospitals and skilled and long-term care facilities have reorganized under the “transitional health-care model.” Previously, discharge was an event. Dramatic reengineering has changed the concept of discharge, from an event to transition as a process. Discharge was episodic and often unexpected; transition is planned and anticipated.

Transition to home or another care facility is a proactive, collaborative process among medicine, nursing, social service, physical therapy, occupational therapy, and nutritionist with each other, with community-based professionals (primary providers, specialists, home care professionals), and with the ill individual and his/her support system.

This collaborative process requires effective communication, early identification of transition date, daily review of status and early identification of barriers, clinicians responsible 7 days a week, and timely access to services in the community.

This complex process takes place in a health-care setting with extreme pressure to discharge or transfer individuals, shorter length of stays, and penalties if individuals are readmitted.

Nurses may view this new emphasis on a safe, timely transition as a means “to save finances” for the health-care institution or the third-party payer. When health-care funds dwindle, the recipients, unfortunately, suffer the most.

Buerhaus and Kurtzman (2008, p. 30) wrote:


Most hospital nurses are salaried; hospitals consider those salaries a cost of doing business. In most hospitals, nurses represent about 40% of the direct-care budget. By contrast, physicians are revenue generators because hospitals charge the CMS and other payers for the costs of the resources used to produce medical care provided by or ordered by physicians. Until now, there hasn’t been a mechanism under Medicare payment policies for measuring nurses’ specific economic contribution to hospitals. CMS-1533-FC offers a mechanism for doing so; to the degree that nursing care prevents costly complications, hospitals will not lose money. In this way, the new Medicare payment rule has the potential to more clearly demonstrate nurses’ economic value to hospitals.

Each day an individual stays in the hospital, the following effects occur:



  • Sleep deprivation


  • Deconditioning


  • Increase in infections


  • Family disruption


  • Sensory overload


  • Nutritional deficits


Early Identification of High-Risk Individuals and/or Family

On admission, all individuals will have a nursing assessment of vital signs, functional health patterns, and body systems (e.g., skin, respiratory, cardiac) using the Nursing Admission Assessment Base. Refer to Appendix B for an example.

After the initial assessment, determine the likelihood that the individual will have an uncomplicated complex transition. For the majority of individuals, the transition will be uncomplicated, as described as:



  • Will usually return to their own home or someone else’s for a short stay


  • Having care needs that can be managed by the individual or support system and do not require complex planning, teaching, or referrals


Uncomplicated transition individuals should be told prior to admission how long they can expect to be in hospital and the time of day they can expect to be discharged, so that they can plan with their support persons.

Only gold members can continue reading. Log In or Register to continue

Dec 6, 2019 | Posted by in NURSING | Comments Off on Transitional Individual/Family Centered-Care1
Premium Wordpress Themes by UFO Themes