Improving Care for Patients Transitioning from Hospital Acute Care to Home

Rosha L. Hamilton, DNP, MSW, BSN; Judith A. Walloch, EdD, RN; Karen Lauer, BSN, RN, MSOLQ; Thomas W. Zoch, MD, FACEP, FACP, CPE


Nurs Econ. 2021;39(2):59-66. 

In This Article

Conceptual Framework

Watson's theory of human caring offers a framework that embraces and intersects with art, science, humanities, spirituality, and new dimensions of mind-body-spirit medicine (Smith & Parker, 2015). This theory reminds nurses to create healing spaces. Where better to do so than in the patient's home? The use of TCM services incorporates all aspects of care for patients and engages multiple care team members, including patients and families. After discharge, outreach phone calls allow nurses to assess the patient for psychosocial, physical, and emotional needs that could serve as a barrier to care. Understanding the patient's strengths and challenges is an essential aspect of care management. Outreach after discharge creates a connection and assists in the education and patient's understanding of the treatment plan. This connection allows for the development of a transpersonal relationship in which the goal is self-healing. This interaction is vital to developing a trusting, caring relationship that supports a healing environment.