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Establishing Goals and Selecting a Course of Action for Transfer of Care

In this unit you have been following the journey of Joseph Russo from the acute- care hospital setting to his return to the community. This assessment requires you to examine how care will be transferred from the hospital to his home. Joseph is being discharged home to the same suburb/town/city in which you live (or have undertaken your most recent PEP), and therefore you will need to seek information on services available to meet his (and his family’s) complex needs in your local community. You will need to consider the transfer of information between differing services during his care transition. Mr. Russo does not wish for his admission diagnosis to be disclosed or discussed. Further information regarding this assessment is provided on the MyLO site.

Criterion 1 Establishes goals and selects a course of action for Transfer of care.

Criterion 2 Demonstrates and applies legal & ethical principles to decision making and incorporates a strengths-based approach.

Criterion 3 Considers culturally safe care in the development of a plan of action 1 & 5

Criterion 4 Writes in a structured, succinct and well-informed manner, substantiating work with scholarly sources. Harvard referencing.

Task: Case Report

In this assessment task, you will be facilitating Joseph's discharge from hospital to his home.

Each student's report will be different as Joseph lives in the same suburb or town in which you reside (or if you wish the location of your most recent PEP). For example, if you live in Norwood, Joseph lives in Norwood, if you live in Sheffield, Joseph lives in Sheffield.  You will be exploring the services and options available in your local community.

This assessment requires you to demonstrate and apply the principles of shared transfer of care and the strengths-based approach to care. You will need to reconnect with the values of strengths-based care

Your strengths based nursing care (SBNC) should not only consider Joseph and his family but also the community strengths. In CNA343 you considered the construct that health and healing are influenced by patient strengths, family strengths and community strengths and how aligns with value 6 (Person and environment are integral), and this will be key to your plan. Another example is the right of Joseph not to disclose his admission diagnosis, which relates to SBNC value 5 (self-determination), which connects to the ethics of respect and autonomy.

This assessment task is not only focused on Joseph; as Joseph was his wife's carer prior to his admission you will need to consider what needs to be put in place to support Joseph and his wife.

This is not an essay, rather a report - which gives you the freedom to include images, tables, flowcharts, headings, forms etc. Please ensure your report has a logical flow.

You may write your report in the first or third person (however do not swap between the two, be consistent).

Joseph wishes to remain in his own home, he does not wish and will not discuss the option of residential aged care for himself or Sophia (Sophia feels the same). Joseph and Sophia will also not discuss respite care options or moving to a smaller house or unit - they want to stay in their own home.

This is an example, a previous student has kindly agreed to me sharing her work. Please note the case study and criteria have both changed since this piece was submitted.

This is another example shared by a student, this student has used clinical reasoning as a framework.

Establishing Goals and Selecting a Course of Action for Transfer of Care

Discharge planning is a process that involves carer, patient, family and staffs involved in the patient care. The aim of the discharge planning is to ensure a safe and a smooth discharge from the hospital, whether to residential care or another location (Hegarty et al. 2014). Discharge planning is an interdisciplinary approach to the continuity of care and the process includes identification, assessment, goal setting, planning, implementing, coordinating and evaluating (Francischetto et al. 2016). A structured patient specific discharge planning reduces the length of the hospital stay, hospital readmissions leading to reduced health care costs.

This report aims to discuss about the course of action of Joseph’s discharge from the hospital and transfer to home. Joseph is an elderly patient would had been admitted to the emergency department for carbon monoxide poisoning. Joseph had undergone brain damage due to the poisoning. He had also displayed symptoms of CLABSI, while in care. Before the discharge he had been diagnosed with a pressure injury at his left heel. Joseph’s wife is not functionally active and normally Joseph takes care of his wife, hence any care plan made for Joseph would also consider the needs of the family of Joseph including the healthcare and the physical needs of Joseph and his wife.  This paper would also demonstrate the legal and the ethical principles for the decision making. While planning for the discharge, Joseph’s cultural aspect should also be considered.

Before the discharge Joseph, there should be a medical evaluation that can comprehensively lay out both the physiological and the psychological condition of the patient,   a short term and a long term outlook and further treatment that the doctor might consider to be necessary (Gonçalves?Bradley et al. 2015). The actual process of discharge planning is normally completed by a discharge planning team or an aged care assessment team (ACAT) that consisted of a physician, a nurse, a case manager, an occupational therapist, a nutritionist and the social worker.  They would assess the physical, medical, cultural, restorative, social and the cultural needs of patients like Joseph. The nurse leaders creates documents explaining the activities and the needs of the patient and hold meetings with the multidisciplinary team to address any escalated issue. They are responsible for making contacts with the referral service and arrange for the follow-up services (Hunter and Birmingham 2013). The multidisciplinary team (MDT) should also consist of an occupational therapist for assisting the patient to cope up with daily activities of living (ADLs), cultivating the life, social skills, relationship and self-efficacy. An OT can also help the personal caregivers to arrange of home modifications suitable to the mobility of the patient (Hickman et al. 2016).   The home carers also play a large role in the discharge planning of Joseph Russo. Emma in this case is Joseph Russo’s daughter and the hence should be involved in the discharge planning.  The social worker in this case would refer to some homecare packages that would supply home support in affordable cost to provide support to both Joseph and his wife Sophia. Joseph Russo stays in Blacktown and there are parent home care support services which can be contacted by the social care workers on behalf of the patient.  

Applying Legal and Ethical Principles to Decision-Making

Since discharge planning involves a proper medical evaluation, it is necessary to keep in mind some of the clinical priorities prior to the discharge (Shepperd et al. 2016). Some of the issues of concern related to Joseph are hypotension, brain damage due to the exposure to carbon-monoxide, chances of a central line associated Blood stream infection (CLABSI). It can also be seen that Joseph had developed a pressure injury on his left heel. Hence, before discharging Joseph, it has to be made sure that all these priorities have been addressed and resolved.  Persistent infection might lead to serious clinical complications in future (Hegarty et al. 2016).   Thus a transfer plan of Joseph would include further assessment of the subjective and the objective symptoms of the patient. Joseph had developed a pressure injury at his left heel and the discharge summary should also consist of a wound management plan. Referrals to allied health specialists such as wound specialist or clinic, a dietician, a podiatrist and a physiotherapist (Hegarty et al. 2016). It is necessary to talk to the patient and the carers about the type of dressing regime that has to be followed. The patient’s family would also be educated about the mandatory reporting in case of an delirium in the patient, as leaving the patient untreated can have adverse effect in the patient . Proper intervention mapping can be considered as a powerful tool for assessing and prioritising the intervention strategies and then tailoring them to the needs of the patient (Hesselink et al. 2013).  The transfer plan would also involve liaising the patient to understand the insurance plans, including the financial assistance to the patient, as well as the cost in home medical equipment and the fees of the medical experts and the home support services (Lopez-Hartmann et al. 2015). There are many support care services in the `black town area, NSW such as The “Anglicare” that provides home care services to help the patient with shopping support, meal preparation and help the patient to lead an active life. Uniting Care health living for the seniors is another support service that provides services in personal care, household assistance, meals and shopping and social support. The community also have provision for “meals on wheels” that are services meant for family like joseph and his wife, where good nutritious food can be provided on ordering. These services are especially meant for the ones that has functional disability or restricted mobility.

Considering Culturally Safe Care in the Development of a Plan of Action

Determination of the responsibilities of the caregivers is also necessary (Lopez-Hartmann et al. 2012). In this case Emma should be educated as of how to take care of Joseph. Joseph’s plan of care would also require counselor or psychiatrist, who can provide psychological support to his family, especially Emma, who was finding hard to juggle between her works, taking care of her father and at the same time look after her son, who suffers from ASD. Emma was constantly suffering from guilt that she was unable to take care of her father, that he had reached this state.

Ethical principles that are widely accepted are taken in to account in many international declarations and recommendations. In case of elderly patients the ethical principles would go further than pure clinical assessment and should include every consequences of starting or withholding care and cure (Morris et al. 2017). The oldest ethical principle is beneficence and non-maleficence, which are the ethical obligations of the physicians and the nurses (Lopez-Hartmann et al. 2017). In this case Joseph should be involved in the decision making process. It is evident from the case study that neither Joseph nor Sophia wants to visit a residential care unit and wants to spend their last days of life in their own house. Although residential care would have been suitable for both Joseph and Sophia, as Sophia has impaired functioning ability due to her health problem and Joseph who used to take care of Sophia was also not in the condition to take care of Sophia or himself, but it is necessary to respect the wish of the elderly people and help them lead a life with integrity and dignity.

Apart from autonomy, another ethical issues that elderly patients often face are the breaching of the privacy and confidentiality of the patient information. It has to be mentioned that patients are always on the vulnerable side as they have to depend for health care. Joseph’s health care information should only be disseminated to the concerned family members and the health care professionals taking care of Joseph, and definitely not with the home support.

Poor communication with the elderly patients can undermine the care provided to the patients. Communicating with the elderly people like Joseph, who had always lived on his own terms can be complex as they might often feel insecured and vulnerable while taking the care. Their cultural background and the wide range of life experiences often influences their perception about illness or their adherence to the medical regimen. Hence it is necessary to communicate with them with respect, empathy and compassion.

Writing in a Structured, Succinct, and Well-Informed Manner

Strength based nursing is an approach where the eight core values guides the action of nursing, promoting hope, self-efficacy and empowerment (Gottlieb 2014). The nurses focuses on the inner strengths and the outer strengths, of the families. Across all the levels of care, from the primary care of the healthy patients to the critical care of the elderly patients. The SBM affirms the nursing goals for the promotion of health, facilitating healing and reducing the sufferings of the patient by the creation of an environment that bolster the capacities for the health and the innate mechanism of healing (Gottlieb 2014). The required nursing assessments involves physical, spiritual, cultural and mental health assessment. Family assessment involves family values and the beliefs, discussion with Emma. Nursing assessment also involved steps like cue collection, in case any health complication is discovered prior to the discharge and then escalating the concerns to the health care teams (Hickman et al. 2016).   Assessment should be done to understand the strength and the weakness of the family that could be utilized in the care.

Culturally safe and respectful practice is not a totally new concept. Culturally safe care helps the nurses to provide care to the nurses in a way that maintains the personal, social and the cultural identity of the patient (Purnell 2014). Provision of a culturally safe care involves using culturally safe words while communicating with the patient, respecting the perception and the culture of the patient by respecting his spiritual or the religious beliefs. According to Nursing and Midwifery Board of Australia (NMBA) (2013) nurses should be able to value or accept the diversity of the people. Again, Joseph might prefer for a female home care support such that her wife does not feel uncomfortable. Hence, gender matching is another step towards the provision of a culturally safe care.


Older people are vulnerable to comorbidities, negligence of care and breaching of the standards. A high rate of hospital readmission has been noticed after the discharge of the planning which could have been avoided by a proper discharge planning. Discharge planning involves involvement of a community services and multidisciplinary team. Furthermore a strength based approach should be taken to empower the patient towards self-efficacy.


Francischetto, E.O.C., Damery, S., Davies, S. and Combes, G., 2016. Discharge interventions for older patients leaving hospital: protocol for a systematic meta-review. Systematic reviews, 5(1), p.46.

Gonçalves?Bradley, D.C., Lannin, N.A., Clemson, L.M., Cameron, I.D. and Shepperd, S., 2016. Discharge planning from hospital. Cochrane Database of Systematic Reviews, (1).

Gottlieb, L.N., 2014. CE: Strengths-based nursing. AJN The American Journal of Nursing, 114(8), pp.24-32.

Hegarty, C., Buckley, C., Forrest, R. and Marshall, B., 2016. Discharge Planning: Screening Older Patients for Multidisciplinary Team Referral. International journal of integrated care, 16(4).

Hickman, L.D., Phillips, J.L., Newton, P.J., Halcomb, E.J., Al Abed, N. and Davidson, P.M., 2015. Multidisciplinary team interventions to optimise health outcomes for older people in acute care settings: a systematic review. Archives of gerontology and geriatrics, 61(3), pp.322-329.

Holland, D.E. and Bowles, K.H., 2012. Standardized discharge planning assessments: impact on patient outcomes. Journal of nursing care quality, 27(3), pp.200-208.

Hunter, T. and Birmingham, J., 2013. Preventing readmissions through comprehensive discharge planning. Professional case management, 18(2), pp.56-63.

Lopez-Hartmann, M., Wens, J., Verhoeven, V. and Remmen, R., 2012. The effect of caregiver support interventions for informal caregivers of community-dwelling frail elderly: a systematic review. International journal of integrated care, 12.

Morris, M.E., Adair, B., Miller, K., Ozanne, E., Hansen, R., Pearce, A.J., Santamaria, N., Viega, L., Long, M. and Said, C.M., 2013. Smart-home technologies to assist older people to live well at home. Journal of aging science, 1(1), pp.1-9.

Nursing and Midwifery Board of Australia (NMBA) 2013, Scope of practice for registered nurses and midwives, NMBA, Melbourne, May 2013, Access date:  17 January 2018, Retrieved from:

Purnell, L.D., 2014. Guide to culturally competent health care. FA Davis.

Shepperd, S., Lannin, N.A., Clemson, L.M., McCluskey, A., Cameron, I.D. and Barras, S.L., 2013. Discharge planning from hospital to home. Cochrane database of systematic reviews, (1).

Hesselink, G., Vernooij-Dassen, M., Pijnenborg, L., Barach, P., Gademan, P., Dudzik-Urbaniak, E., Flink, M., Orrego, C., Toccafondi, G., Johnson, J.K. and Schoonhoven, L., 2013. Organizational culture: an important context for addressing and improving hospital to community patient discharge. Medical care, 51(1), pp.90-98.

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