The pathway for patient transitioning

Initial question:
Outline the pathway for patient transitioning from primary care to the inpatient setting, then discharging to home setting and returning to primary care- setting for follow up appointments. Please include potential needed nursing resources at each point of care, challenges that might occur during these transitions, and prevention the nurse can do to ensure smooth movement
on the continuum of care.

Please respond to:

Some hospital admissions begin with a patient visiting their primary care doctor regarding a problem or an annual check-up. When the doctor finds a concerning problem via physical assessment or labs, they will recommend they go to the ER. From the ER, the medical professionals assess their need to be admitted via scans, imaging, labs, vitals, physical assessment, etc. If the patient needs to be admitted to the hospital, the admitting nurse will go through a series of questions regarding current safety at home, the safety in returning back to their living situation, any other concerns regarding their admitting diagnosis, and a comprehensive physical assessment to help monitor any changes throughout their admission. Let’s say that the patient was confused and/or had trouble getting around, our admission process would likely trigger a case management consultant who would then visit the patient the next day or shortly thereafter to address if it is safe to go home or not and if not, they will help coordinate a plan. If the patient has wounds, a wound care consult can be placed at admission, if they have nutritional deficits, there can be a dietary consult, if they have religious needs, we can get a clergy in the room, etc. The nurse can make all of these transitions that may feel overwhelming for a patient, easier, by listening & being empathetic.

When getting discharged, the bedside RN will go through education materials and a discharge packet that goes over the next doctor’s appointments, when to call the doctor, and when to go to the ER, they will put in any new mediation scripts. In summary, discharge instructions play several critical roles. They help a patient understand what is known about their condition and what was done for them in the emergency department. They also provide a plan for treatment and follow-up and reasons to return to the emergency department (SAEM.org, n.d.).Some hospital admissions begin with a patient visiting their primary care doctor regarding a problem or an annual check-up. When the doctor finds a concerning problem via physical assessment or labs, they will recommend they go to the ER. From the ER, the medical professionals assess their need to be admitted via scans, imaging, labs, vitals, physical assessment, etc. If the patient needs to be admitted to the hospital, the admitting nurse will go through a series of questions regarding current safety at home, the safety in returning back to their living situation, any other concerns regarding their admitting diagnosis, and a comprehensive physical assessment to help monitor any changes throughout their admission. Let’s say that the patient was confused and/or had trouble getting around, our admission process would likely trigger a case management consultant who would then visit the patient the next day or shortly thereafter to address if it is safe to go home or not and if not, they will help coordinate a plan. If the patient has wounds, a wound care consult can be placed at admission, if they have nutritional deficits, there can be a dietary consult, if they have religious needs, we can get a clergy in the room, etc. The nurse can make all of these transitions that may feel overwhelming for a patient, easier, by listening & being empathetic.