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3 guides on this topic

Care transitions

What each care transitions question is really asking, how to structure the answer, and where the marks are likely to sit.

Develop one component of a nurse-run outpatient heart failure clinic — an Orientation Course Plan, a Discharge Education Plan, or a Care Coordination Plan — as a 3-4 page evidence-based delivery plan built against the clinic's stated enrollment, education and readmission goals.

A 20-minute video presentation teaching staff-nurse colleagues care coordination basics — collaboration strategies, change management's patient-experience effects, the ethical rationale for coordinated plans, and policy impacts — with a 4-5 page narrative script that is delivered, not submitted.

The spectrum is the point: what fails between acute care and home is the handoff, and a plan that names a technology for each setting without naming what carries information between them has missed the assignment.

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