Systems Thinking
Systems thinking, in my own words, is a system in which all the parts work together in a way that makes them interdependent to reach the goal of the system. It is a way to find a goal, figure out what it is made of, and see how its parts fit together. Arnold and Wade (2015) say that system thinking is a “set of synergistic analytic skills used to improve the ability to recognize and understand systems, predict how they will behave, and come up with ways to change them to get the results you want.” The skills work as a system.”
Macrosystem-level Transition of Care
When someone is admitted to the hospital, they often move from the hospital to a nursing home. This is a large-scale change in care that many people go through. People are moved from hospitals to nursing homes when they aren’t back to normal and wouldn’t be able to take care of themselves at home. The name, “nursing home,” gives away the goal. Nursing homes are set up like homes, but nursing care is available around the clock. It is the time when the patient goes from the hospital to his or her own home. The people who are going to nursing homes are still sick, though, and if they don’t get good care and aren’t watched carefully, they will end up back in the hospital. Caruso, Thwin, and Brandeis (2014) found problems with the change. When the patient was moved to a new care facility, the hospital provider’s recommendations were not followed. This led to a higher rate of readmission for both the patient and the hospital. In this transition, getting out of the hospital and getting to the nursing home with discharge instructions are two points on a continuum. Britton et al. (2017) found things that make it hard for people to move smoothly into skilled nursing facilities. Four main ideas came out of the study: the increasing complexity of patients, finding the best place to give care, increasing financial pressure, and barriers to good communication. When people leave hospitals and go to nursing homes, they are sicker than they were years ago. They are on multiple medications and use specialized medical equipment, and they are always on the edge of needing to go back to the hospital. This is very hard for the staff at the nursing home and means that the patient needs more technical and time-consuming care.
The quadruple aim is to improve the health of populations, improve the experience of care for individuals, lower the cost of healthcare per person, and help people find happiness at work (Institute for Healthcare Improvement, 2019). It can be hard to move from a hospital to a nursing home because many things can go wrong and hurt the patient and their care. Leaders of nurses in both places need to work on making communication better. Local hospitals should help nursing homes put money into electronic health records (EHR). If the two organizations’ EHRs are compatible, it will make it easier for them to talk to each other and share important information about the patient. By investing in a compatible EHR, the cost of health care per person will go down, and nursing care will be more efficient and tailored to each patient’s needs. Another way to improve the transition to nursing home care is to better meet the patients’ needs by combining social work and general medicine services (Britton et al., 2017). More help from other fields will make it easier for the patients to move from the hospital to the nursing home.
References
Arnold, R. D., & Wade, J. P. (2015). A definition of systems thinking: A systems approach.
Procedia Computer Science, 44, 669-678.
Britton, M. C., Ouellet, G. M., Minges, K. E., Gawel, M., Hodshon, B., & Chaudhry, S. I.
(2017). Care transitions between hospitals and skilled nursing facilities: Perspectives of
sending and receiving providers. Joint Commission Journal on Quality and Patient
Safety, 43(11), 565–572. https://doi.org/10.1016/j.jcjq.2017.06.004
Caruso, L.B., Thwin, S. S. & Brandeis, G.H. (2014). Following up on clinical recommendations
in transitions from hospital to nursing home. Journal of Aging Research, 2014.
https://doi.org/10.1155/2014/873043
Institute for Healthcare Improvement. (2019). The triple aim or the quadruple aim? Four points
to help set your strategy. Retrieved from https://www.ihi.org/communities/blogs/the-
triple-aim-or-the-quadruple-aim-four-points-to-help-set-your-strategy

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