Naylor's Transitional Care Model, adapted for one composite man with cirrhosis, joins hospital, home and community services under a single coordinator, with hospice triggers agreed ahead, in NU475's closing proposal. Searches like "nu 475 unit 10 assignment example", "nu475 unit 10 sample" and "nu475 unit 10 example" land here.
One Plan, One Coordinator, Three Settings: A Transitional Care Proposal for a Retired Mail Carrier With Decompensated Cirrhosis
[Student Name]
Purdue University Global
NU475: Providing Transition Care - Chronic Disease and Palliative/Hospice Spheres
Unit 10 Assignment
[Instructor Name]
[Date]
Composite patient, hospital and town written as a model document. Costs and thresholds are bracketed; nothing here is a prescribing instruction.
Summary for the Transitions Committee
Request: assign one advanced practice registered nurse to this patient from his next admission through [90] days at home, following the core of the Transitional Care Model. The nurse would visit him in the hospital, lead the discharge, visit at home, accompany him to key appointments by phone or in person, and hold the single plan below. Cost: about [0.05] FTE of an existing transitions nurse for [90] days, or [$3,900] at the hospital's loaded rate. Measures: readmissions, emergency visits, days at home, caregiver preparedness and whether his preferences are followed.
Why This Model
Three models were weighed.
Project RED. Already used at this hospital for his discharge. It organizes the discharge well and ends with one phone call; in its trial it reduced combined readmissions and emergency visits within 30 days (Jack et al., 2009). His risks continue far beyond the discharge, so RED alone is not enough.
The Care Transitions Intervention. A coach helps the patient manage medicines, keep a personal health record, arrange follow-up and recognize red flags, and in a randomized trial it lowered rehospitalization at 30 and 90 days (Coleman et al., 2006). It depends on patient activation, a capacity his episodes of hepatic encephalopathy undermine, and it places most of the work on him or his wife.
The Transitional Care Model. An advanced practice nurse follows the patient from hospital to home and manages clinical change there. In a randomized trial with hospitalized older adults at high risk, it reduced readmissions and costs over six months (Naylor et al., 1999). In a later trial limited to older adults with heart failure, it lengthened the time to readmission or death and reduced costs over a year (Naylor et al., 2004). It fits him best because it follows him into the home and manages the clinical changes, such as diuretic doses and lactulose titration, that are most likely to bring him back.
A caution: no trial of this model has been limited to patients with cirrhosis, and its evidence comes from older adults with mixed conditions and heart failure. The proposal treats it as a well-supported model applied to a new population, and the measures below are chosen to show whether it works for him.
The Grid
Each row lists what happens in the hospital, at home and in the community, with an owner in each cell.
Medications
Hospital: reconciled list from Unit 3; corrected [spironolactone] order. Owner: pharmacist.
Home: blister packs; [lactulose] titration by stool count. Owner: wife, with transitions nurse.
Community: one pharmacy for all fills. Owner: pharmacist.
Symptoms
Hospital: IPOS scored on admission. Owner: palliative team.
Home: IPOS rescored at each home health visit; the symptom brief from Unit 8 in the chart. Owner: home health RN.
Community: faith community nurse at his church checks in weekly after services. Owner: faith community nurse.
Caregiver support
Hospital: caregiver assessment from Unit 5 repeated if his condition changes. Owner: transitions nurse.
Home: teaching sheet from Unit 9 on the refrigerator; teach-back at each visit. Owner: transitions nurse.
Community: National Family Caregiver Support Program referral; son's days off for procedures. Owner: case manager.
Planning
Hospital: goals reviewed at each admission. Owner: palliative team.
Home: preferences recorded in his words and shared with every setting. Owner: transitions nurse.
Community: copy of his plan at the local clinic. Owner: primary care nurse.
Escalation
Hospital: palliative team involved at every admission. Owner: hospitalist.
Home: calls the transitions nurse first for any warning sign on the teaching sheet. Owner: wife.
Community: county paratransit for paracentesis; 911 for the three emergency signs. Owner: wife and son.
Community entries are concrete: sodium-limited home-delivered meals through the Area Agency on Aging, the faith community nurse at his church, and paratransit on paracentesis days, booked a week ahead.
Hospice Triggers, Agreed in Advance
Palliative care is already involved. Hospice is raised, in a planned conversation with him and his wife, when any two of these occur:
Paracentesis needed weekly.
Palliative Performance Scale below [50] percent.
[Two] admissions in [90] days.
A second episode of hepatic encephalopathy despite adherence to [lactulose] and [rifaximin].
He agreed to these triggers at his last palliative visit and said he would rather "hear it from the nurse I know than from a stranger in the emergency room." The triggers do not decide for him; they decide when the conversation happens.
Measures
Readmissions at 30 and 90 days.
Emergency visits at 30 and 90 days.
Days at home in the 90 days.
Wife's Preparedness for Caregiving Scale mean at day 0 and day 90.
Whether his recorded preferences were followed at any admission, by chart review.
Sustainability
Medicare transitional care management codes pay for services in the 30 days after discharge when the practice reaches the patient or caregiver by phone, message or visit in the first two business days and a face-to-face visit follows within 7 days for high complexity or 14 days otherwise (Centers for Medicare & Medicaid Services, n.d.). These codes can offset part of the nurse's time for the first month. The remaining [60] days would come from the hospital's transitions budget. If the measures show fewer admissions and more days at home, the committee could extend the model to other patients with decompensated cirrhosis, a small group with high readmission rates.
References
Centers for Medicare & Medicaid Services. (n.d.). Transitional care management services. Medicare Learning Network.
Coleman, E. A., Parry, C., Chalmers, S., & Min, S. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822-1828. https://doi.org/10.1001/archinte.166.17.1822
Jack, B. W., Chetty, V. K., Anthony, D., Greenwald, J. L., Sanchez, G. M., Johnson, A. E., Forsythe, S. R., O'Donnell, J. K., Paasche-Orlow, M. K., Manasseh, C., Martin, S., & Culpepper, L. (2009). A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Annals of Internal Medicine, 150(3), 178-187. https://doi.org/10.7326/0003-4819-150-3-200902030-00007
Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004). Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society, 52(5), 675-684. https://doi.org/10.1111/j.1532-5415.2004.52202.x
Naylor, M. D., Brooten, D., Campbell, R., Jacobsen, B. S., Mezey, M. D., Pauly, M. V., & Schwartz, J. S. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA, 281(7), 613-620. https://doi.org/10.1001/jama.281.7.613
How this NU475 Unit 10 example is structured
Choice of model is argued before the plan. Three options are weighed in a short table: Project RED, already used at discharge but ending at the hospital door; a coaching model centered on patient activation, which assumes a capacity his encephalopathy episodes undermine; and Naylor's nurse-led model, which follows him into the home and manages clinical change. The third wins on fit, its evidence summarized from randomized trials in hospitalized older adults, including one limited to heart failure, with a caution that cirrhosis evidence is thinner. The grid follows, then escalation, which is where palliative and hospice care enter: a palliative team already involved, and hospice raised when any two triggers occur, such as paracentesis needed weekly, a Palliative Performance Scale below 50 percent, or two admissions in 90 days. Measures and a modest staffing cost end the proposal.
Get an NU475 Unit 10 example written to your instructions
Earlier assignments from this course, even rough ones, give the closing proposal something to integrate, so attach them next to this last prompt and the rubric that scores it. From those pieces the desk builds one plan across hospital, home and community, keeping each earlier finding consistent, and returns it in 24-48h; a first request costs nothing. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.
NU475 Unit 10 questions, answered
Can the proposal reuse my earlier assignments?
Most closing prompts expect it, since the point is integration. Carry forward the parts that still hold, such as a reconciled medication list or a caregiver assessment, and revise anything the later units changed. The sample cites its own earlier pieces by name and updates two of them, so the reader can see continuity rather than repetition.
Which transitional care model is best supported by evidence?
Naylor's Transitional Care Model has randomized trial support in hospitalized older adults, and Coleman's Care Transitions Intervention and Project RED have trials of their own. Each fits a different need: clinical follow-through at home, patient coaching, or the discharge process. Argue the match to your patient rather than ranking the models in general, and note where evidence for your condition is limited.
Where should hospice appear in a coordinated care proposal?
Inside the plan, not after it. The strongest proposals keep palliative support running throughout and define in advance what would prompt a hospice discussion, so the transition is planned rather than rushed. The sample lists three triggers agreed with the patient and names who raises the conversation when two of them occur.