Owing to the increasing rates of hospital readmissions arising from poor transitional care it is essential to implement a program that will see to it that the current challenges facing transitional care are addressed and that there is an increase in specialized nursing to help foster the provision of transitional care. Currently, the health care committee has proposed a number of interventions that need to be implemented by the project manager to see the improvement of transition care, especially in relation to dealing with elderly patients (Morphet et. al., 2014). Some of these interventions that have been proven to result in the reduction of patient readmission rates among them patient needs assessment, patient education, medication reconciliation, timely outpatient appointment as well as the provision of telephone follow-up services (Morphet et. al., 2014).It is essential that once the patients are discharged from hospitals that they continue to receive enhanced communication, medication safety and that their caregivers receive advanced care planning and training on how to best manage the associated common medical conditions (Ortiz, 2019). As a result of the currently proposed interventions, the project aims to target the challenges on transition care by defining the role of home-based services, the significance of caregiver support, community partnerships and the importance of new transitional care personnel (Ortiz, 2019). The project manager has gone as far as proposing the time frame that it will take to see the realization of the effects of the project, a practical budget as well as the resources and tools that will be used in the project to see the successful realization of the transitional care program.

The Time Frame of the Project

Ascertaining the current state of Transitional Care in Hospitals (Patients Admissions, Level of Communication and Coordination among the Nurses, Level of Interaction between the Healthcare providers and the Nurses) 6 months
Ascertaining the Level of Nursing Expertise in Hospitals (Level of Education and Expertise of the Nurses) 6 Months
Making Home Visits to the Patients to Ascertain the Level of Expertise of the Caregivers 6 Months
Consolidation of the Collected Results 6 Months

The enactment of the transitional care program includes the inclusion of a defined timeline on how the different roles will be attained. Going by the evaluations by the project manager, the planned timeline that it will take to achieve concrete improvements includes having six scheduled visits to the hospitals for two years. The two-year time frame includes a close working relationship with elderly patients, health care providers, as well as the patient caregivers, all of whom are key stakeholders in the transitional care process. The first six months of the proposed time frame will include the use of the observation method to ascertain the current state of transitional care in the hospitals. In this time frame, notes will be taken on how the parents are received in the hospitals, their admission to the emergency departments, the communication and coordination of the nurses when dealing with the elderly patients, as well as the level of interaction between the caregivers and the health care providers in the event that the patients are released from hospitals.

The second half of the first year will be solely used to ascertain the level of nursing expertise in regards to transitional care. Past studies, as well as the Masters’ Essentials, have ascertained that the use of unspecialized nurses remains to be one of the key challenges facing the provision of health care services. Additionally, previous observations and studies have established that there remains to be a significant difference in the provision of services given by masters-level nurses and those below the master’s level unit. Hence, the six-month-time-frame will be used to interact with the nurses providing transitional care, to determine their level of education and training as well as their experience when it comes to the provision of transitional care. Additionally, the observation method will come in handy to observe the differences in the provision of services by both the specialized and unspecialized nurses.

The next six months of the second year will be used to make visits to the patient homes, to determine the level of expertise held by the caregivers in relation to caring for the patients as soon as they are discharged from the hospitals. The key activities in this allocated time will involve holding conversations as well as interviews with the caregivers to ascertain their level of preparedness, education, and expertise in relation to taking care of the patients as a means to reduce the high rates of hospital readmissions. Additionally, the time frame will be used to observe how the patients respond to the care provided by their caregivers, as well as their level of comfort and how fast their get back to their health as soon as they are discharged.

The last six months of the allocated time-frame will be used to consolidate the different results collected and to revisit areas with inadequate information as a means to eliminate any existing biases or inconsistencies in the results. Therefore, the allocated two-year time-frame for the project will be adequate to see to it that all the existing challenges in transitional care are adequately addressed.

Budget for the Project

For the proposed activities to be accomplished in the allocated time, a budget will be put in place to ensure that all the activities are tackled within the proposed budget and that the total costs do not exceed the existing working revenues. The project manager has proposed a working budget of $9000, and below are the key expenses that will be incurred throughout the project:

1. Employee Compensation ($4000) – Collection of data from the patients, health care providers as well as the caregivers will involve working with a team of about ten members all of whom will have to be compensated through the provision of wages as well as other benefits and incentives.

2. Contract Services ($1500) -The project will involve frequent outsourcing of different health care providers who will be compensated by means of part-time wages whenever their consultancy services are called upon.

3. Equipment/Supplies ($1000) – To facilitate the activities of the project a number of office equipment/supplies will be required among them office supplies, postage, computer supplies, consumables, equipment repair and maintenance, office equipment among other supplies.

4. Travel/Related Expenses ($1500) – For the related activities to be carried out travelling is inevitable, and hence with $1000, the program manager is certain that all travelling expenses among them air travel, out of town expenses, daily parking, mileage expenses among others will be well catered for.

5. Overhead/Indirect Costs ($1000)- Lastly, there will be a $1000 allocation budget to ensure that all overhead expenses (indirect costs) are catered for hence allowing for the project to cater for administrative as well as daily operations costs.

Resources/Tool Required for the Project

For the project to be successful different resources and tools will be required in ensuring that all the stakeholders effectively take part in the project. The key resources include patient/family materials, hospital models, as well as key personnel who will be involved in running the project.

Patient/Family Resources

a. Family Discharge Planning Checklist

This is a tool that provides patients and caregivers with a list of questions that should be answered prior to the patient discharging process (Ortiz, 2019).

b. Next Step in Care

This is a website that provides caregiver resources and checklists, ensuring that caregivers are aware of how to take care of the patients before they are discharged from hospitals (Ortiz, 2019).

c. Patient PASS: A Transition Record

This is a document that includes patient requirements that will result in the safe transitions of the patients from the hospitals to their homes (Storm et. al., 2014).

d. Personal Health Record

This is a patient health record information that includes a checklist of all the activities that patients must do to manage their care better (Storm et. al., 2014).

e. Patient Discharge Planning Checklist

This is a resource that includes a patient checklist where patients and caregivers respond to different questions before they are discharged from the hospitals. Some of these questions include patient care needs, options for continued care, community-based resources, and post-discharge care instructions (Storm et. al., 2014).

The above mentioned resources will play a key role in the project, as they are targeted towards improving transitional care by ensuring that all the involved stakeholders use key documentation in the transitional process thus ensuring that the patients are in safe hands as soon as they discharged and that the caregivers are well educated on how to deal with the patients as a means to reduce instances of hospital readmissions.


Morphet, J., Griffiths, D. L., Innes, K., Crawford, K., Crow, S., & Williams, A. (2014). Shortfalls in residents’ transfer documentation: Challenges for emergency department staff. Australasian Emergency Nursing Journal17(3), 98-105.

Ortiz, M. R. (2019). Transitional Care: Nursing Knowledge and Policy Implications. Nursing science quarterly32(1), 73-77.

Storm, M., Siemsen, I. M., Laugaland, K., Dyrstad, D., & Aase, K. (2014). Quality in transitional care of the elderly: Key challenges and relevant improvement measures. International journal of integrated care14(2).

Ye, Z. J., Liu, M. L., Cai, R. Q., Zhong, M. X., Huang, H., Liang, M. Z., & Quan, X. M. (2016). Development of the Transitional Care Model for nursing care in Mainland China: A literature review. International journal of nursing sciences3(1), 113-130.


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