Video Reflection Summary for Phase 1
I made a transitional care plan for Donald with an Acute Myocardial Infarction
from Scenario I. He is a 55-year-old Hispanic male being discharged from the
hospital after angioplasty and placement of 2 stents. When studying the
scenario, I looked for cues about what would be the most important thing to
provide for this patient when discharging. He had a good social support
system, with his wife and two children living at home, as well as extended
family nearby. I determined Spanish was likely his first language, so
providing him with information in Spanish and English was appropriate and
important. He ate out a lot, so information on a healthy, cardiac diet with
appropriate and regular exercise was a significant part of the transition plan.
But medications and follow-up care were the most important discharge items
to address for Donald. Understanding his medications, side effects, and any
future symptoms to look for was a priority. A cardiology follow-up
appointment was made at discharge, and making an appointment for
primary care was left in the patient and family’s responsibility.
Donald had a good background for his discharge education due to his
education, social support, and economic resources, which enabled him to
address pertinent aspects of his discharge plan. Barriers for many patients
can include language and many other social determinants. What I learned is
that everyone’s discharge plan is going to look a little different, but
examining all important areas to avoid gaps in patient care and reduce
hospital readmissions is crucial for post-MI patients. It caused me to pause
and think about how this process went at my hospital, and it gave me great
appreciation for the case managers and the electronic health record. I am
glad that the discharge plans are easy to follow at my hospital, and I can
easily identify any items that may be missing from the plan and work to
ensure the patient receives what they need to facilitate a positive transition
of care.
