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Phase 4-Results

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Project Results

The project aimed to identify the main challenges facing transitional care, to determine the impact of unspecialized nursing on transitional care, and to identify the importance of specialized nursing in the provision of transitional care. The results of the study identified five significant challenges facing the quality of the provision of transitional care to the elderly patients all of which were inclusive of the failed roles played by different parties among them the nursing personnel, the caregivers as well as the patients.


From the study, it was identified that a majority of the elderly patients had caregivers which hindered the provision of transitional care. Nonetheless, the patients with caregivers echoed that they played an essential role in their transitional care, for example by providing essential information to the nurses on the patient’s health and also by providing adequate self-care to the patients during both the admission and the discharge process. However, despite their significant role, the caregivers were required to consult with the health care personnel during the admission and patient discharge transitions in order to acquire more information on their patient’s health condition, medications, and surgical operation among others (Allen et. al., 2014). The study identified that in most cases, the caregivers were neither informed nor prepared about the patient’s discharge process, often questioning the nurses on whether their patients were entirely ready to be discharged. Additionally, the study identified that the caregivers placed high expectations on the nurses and the health care personnel, where the caregivers expected the health care personnel to offer adequate care to the patients until they were fully recovered and often the caregivers were not prepared to extend any transitional care services to their patients.

Patient Characteristics

From the study, it was evident that upon admission a majority of the patients suffered from various chronic conditions as well as other minor diagnoses among them pain, nausea, fatigue, diarrhea, hearing loss, walking problems among others. However, upon admission, most of the patients only presented characteristics of the main chronic conditions while ignoring the symptoms associated with the minor diagnoses. As a result, such patients were not prioritized during the admission process, forcing them to wait longer in the emergency department. These resulted in the development of symptoms like increased confusion, dizziness, anxiety, tiredness, and even pains and trouble when walking when the patients were discharged from the hospital (Leyenaar et. al., 2016). Additionally, the study identified that most of the elderly patients experienced post-discharge infections. From the interviews and responses gathered, most of the patients echoed that they were satisfied with the information and level of professionalism and care are given to them during the hospitalization process, but they were largely dissatisfied with the long waiting time during the admission process. Moreover, most of the patients mentioned that they were unprepared for discharge, which often resulted in increased confusions and anxiety during the transition process.

Level of Expertise among the Health Care Personnel

From the study, it was established that there exist formal routines in the admission and discharge transitions; however, at the time of the study, a majority of the physicians working in the emergency department were interns who were very inexperienced in the admission transitions (McDonagh& Kelly, 2010). Hence, the study illustrated a lacking in their technical part, where they required to have more experienced health care personnel to ensure effective clinical assessment of the patients during the transition process. Also, the study identified that during the patient discharge process, the chief physician, as well as the ward nurse, dictated the type of treatment to be taken by the patients as well as when the patients were ready for discharge. Moreover, it was identified that during the discharge process, most of the nurses lacked familiarity with the medical history of the patients, and often it complicated the attainment of a sound transition process.

Communication/Information Exchange

From the study, it was identified that information during the transitional process was transferred in three main ways: oral, written, and electronic. During admission, the caregivers were tasked with providing key information regarding the health and condition of the patients, however, in most cases, the delivery of the information was not consistent as a result of factors like missing nursing reports and tests during the discharge or the provision of unclear information regarding the patient’s current medication (Baronov& Evan, 2018). As a result of the inconsistencies in the communication process, the health care personnel experienced an even harder time and were frustrated when ascertaining the patient’s health condition, their medical history as well as the right medication for their condition. Moreover, the study identified that in certain hospitals, there lacked a fully integrated computer system which often complicated the entire transition process. However, the nurses played a key role in coordinating information exchange during the transition process, where at discharge, the nurses were in constant communication with the caregivers regarding the patient’s health condition.

Lack of Patient Assessment

Upon arrival at the hospitals, a majority of the elderly patients presented morbidity and age-related impairments.  Even worse, the patients spent hours in the emergency departments without being clinically assessed by the physicians. This resulted in frustrations on the nurses taking care of the basic needs of the patients, resulted in delayed medical assessments and complicated the patient transfer process to the wards. Additionally, at discharge, the patients did not undergo any systematic assessment of their cognitive status often as a result of the lack of familiarity of the patient illness history by the nurses and also labeling the patients as being ready for discharge based on an analysis of their primary illness only (Chen, 2016). The study actually observed that a majority of the physicians paid close attention to the current conditions of the patients while failing to take into account earlier diagnosis, which in most cases resulted in the quick readmissions of the patients back to the hospital.


As seen above, the study helped to illuminate the current challenges facing the provision of quality transitional care to elderly patients. The results portray a combination of complex and interconnected challenges involving, the health care personnel, nurses, and caregivers, all of which should be addressed by means of multiple improvement measures. The observational data used for the study also indicates the lack of real-time studies on transitional care practices hence negatively impacting the provision of effective transitional care. Therefore, there is an urgent need to implement effective strategies aimed at improving the attitudes of the health care personnel, the knowledge, and level of expertise held by the caregivers in relation to transitional care and also imposing transitional care knowledge and skills across the different levels of health care delivery.  These steps serve as the foundation in supporting the organizational cultures that have for years focused on quality care in transitional care for the elderly.


Allen, J., Hutchinson, A. M., Brown, R., & Livingston, P. M. (2014). Quality care outcomes following transitional care interventions for older people from hospital to home: a systematic review. BMC health services research, 14(1), 346.

Baronov, D. V. & Evan J. B. (2018).Systems and methods for transitioning patient care from signal based monitoring to risk based monitoring. U.S. Patent Application 10/062,456, filed August 28, 2018.

Chen, E. T. (2016).Examining the influence of information technology on modern health care.In Effective Methods for Modern Healthcare Service Quality and Evaluation (pp. 110-136).IGI Global.

Leyenaar, J. K., Desai, A. D., Burkhart, Q., Parast, L., Roth, C. P., McGalliard, J., … &Gidengil, C. A. (2016). Quality measures to assess care transitions for hospitalized children. Pediatrics, 138(2), e20160906.

McDonagh, J. E., & Kelly, D. A. (2010).The challenges and opportunities for transitional care research. Pediatric transplantation, 14(6), 688-700.

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