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The Patient With Acute Myocardial Infarction: Transition Plan


Healthcare facilities face challenges in reevaluating their facilities’ transitional care practices to reduce the 30-day readmission rate. Notwithstanding the intensified focus on transitional care, researchers have conducted few studies to show a recommendable reduction in readmission rates, especially with patients suffering from acute myocardial infarction (MI). Patients’ transition increases the risk of adverse effects since responsibility is often delegated to new parties, thus increasing miscommunication. A decade ago, the Centers for Medicare and Medicaid Services (CMS) penalized several US hospitals for unnecessary 30-day-readmission rates for patients suffering from MI. The paper will focus on Care Transition Plan for patients suffering from acute myocardial infarction (MI).

Phase 1

The Evidence-Based Practices for Effectively Transitioning Patients from the Hospital to Home with the Specific Focus on Preventing 30-Day and Long-Term Disease-Specific Readmission

The patient and the caregiver should be trained on the discharge day and informed on managing the MI. Additionally, the patient should be encouraged to emulate the forms of services he received from his five-day stay in the hospital to improve his health. As a result, the patient will be cautious of every activity he is undertaking regarding his health conditions, thus eliminating possible readmission.

Owing to the delicate nature of the patient discharged, the institution should ensure that the patient keeps a follow-up appointment within one week of being released from the hospital. This will enable the facility to assess the patient’s condition and check if his situation is improving or deteriorating (Hocutt, 2017). Through this, the facility will give an earlier opinion regarding the patient’s state, thus eliminating readmission.

The facility should also assign a patient a navigating tool to manage and monitor their post-discharge care. The instrument should comply with the medical standards and perform the function s which it intends to conduct. Though, the patient can assess his situation without relying on the medics, the navigator can provide crucial information to the patient. Thus, he can always take medicine depending on what the indicator shows (Hocutt, 2017). As a result, the situation will be managed, thus eliminating readmission within 30 days of discharge.

The facility should also confirm the medication plan that is supposed to be used by the patient and harmonize all discharge medication. Ensuring that the medication plan does not conflict with the initially prescribed medication will eliminate some effects of the prescribed drugs’ incompatibility. According to Albert (2016), some drugs react in the body when they are taken simultaneously. Harmonizing the medication plan will also ensure that overdose is prevented since some medications may have the same content, thus performing the same function when consumed.

A CMS HRRP Conditions Care Transition Plan for the Patient with Acute Myocardial Infarction (MI)

Phase 1 CMS HRRP Transition Plan
Components Action Time/Duration/Frequency Persons/Resources
Individual -Educating the patient on the type of medication they should be taking
-Visit the facility for Follow-up
-5 days within the admission -The physician and the registered nurses (RNs)
Social -Going to church -Ones per week -Family members
Community -Participating in community activities -Every month -Community members
System-level -Medication reconciliation
-Discontinuation from high-risk medication
-The day of discharge -The doctor
-Mr. D and the family members
Condition/procedure -Checking the health condition of Mr. D
-Every week -The physician
Phase 2 Evidence-Based Practices Transition Plan
Individual -Performing physical exercise
-Ensuring good communication
-Twice a day
-Every time a communication is made
-The patient (Mr. D)
Social -Interacting with friends and relatives
-Spending more time with family members
-Every day -Family members and Mr. D
Community -Participation in community activities such as environmental cleaning
-Interacting with community members
-Every month – Community members
System-level -Taking the drugs at the prescribed time -Every day -The patient
Condition/procedure -Noting critical changes in the body -twice a day -The patient

Phase 2

The Evidence-Based Practices for Effectively Transitioning Patients from the Hospital (& Rehabilitation Unit) to Home with the Specific Focus on Preventing All-Cause Hospital Readmission

Communication is an EBP that needs to improve to reduce 30-day readmission. Hospitals can have a perfect plan of enhancing a patient’s safety and wellbeing. However, if there are poor strategies for communicating the goal, the desired results might not be achieved. Poor communication can result in the patient’s death or long-term effects that might affect the patient’s life. According to Hocutt (2017), clinicians can only offer a proper solution when they communicate with the patient and other physicians effectively. The leading cause of readmissions is the miscommunication and misunderstanding that is often experienced when transferring patients. Therefore, the facility should organize a simple medication instruction that the patient understands before moving and communicating with the primary doctor on any changes that may be witnessed.

Secondly, heart care can adopt healthcare technology solutions as an EBP. The world is continuously changing, and the field of medicine has adopted the use of technology. According to Albert (2016), several telecommunication techniques can reach patients without the doctor physically attending to the patient. Therefore, the institution should ensure that a doctor checks on Mr. D daily using telecommunication services. This will ensure that the facility gets daily updates on the patient’s progress; hence they can decide on the future medication plan to improve his wellbeing (Hocutt, 2017). Moreover, technology can be used to store the patient’s data and information. Through integrated data management, the nurse in charge of the patient will ensure that the patients’ medical information is updated daily.

Phase 3

Patients suffering from acute myocardial infarction (MI) are prone to get hospitalized. Their situation is often delicate since it is unknown when a heart attack will occur. Although some patients recover from the problem, most usually have lasting adverse effects, while some end up dying. However, various primary, secondary, and tertiary plans are put in place to enhance people’s lives suffering from heart attack condition.


The primary ways are the plans that are put in place to prevent the disease from occurring. In other words, they are anticipatory methods that seek to prohibit causes of the disease. For instance, increased consumption of vegetables increases the blood flow in the body, thus reduces the chances of experiencing a heart attack. Performing family medical history is another primary way of preventing hospitalization since it makes an individual determine the probability of the disease’s occurrence because it is also inherited (Mehta et al., 2016). Moreover, these ways can be performed individually, through medical personnel, or community participation.


Secondary procedures involve methods that can help in identifying the disease at an earlier stage. As a result, it reduces the effects of the condition that are usually disastrous signs the patient is unlikely to survive if they experience the disease at a late stage. Although MI is never treated, it is generally controlled, thus prolonging the life of the patient. The secondary procedure reduces the medication cost experienced when the disease is detected later (Piepoli et al., 2017). This usually occurs because there are no complex medications such as surgery that is required at this stage.


The tertiary methods manage MI at an advanced stage when the diseases have already been diagnosed. They are meant to control the disease or stop the occurrence of a heart attack. It is the most expensive method since it is experienced at an advanced stage, and it often involves complex treatment such as heart surgery to remove the blood clots. The heart has been destroyed; the method is used to rehabilitate the cardiac system, which is usually a delicate procedure.

Hospitalization Prevention Plan

Composition Methods
Primary Secondary Tertiary
Individual – Reduce the alcohol consumption
– Regular consumption of grains and vegetables
– Reduced sugar and cholesterol consumption
Frequent blood pressure screening Cardiac rehabilitation for the patient
Social Visit a physician when there is constant chest pain. Avoiding stress Visiting a physiotherapist
Community Avoiding secondhand smoke Promoting community awareness Ambulatory services
System-level Performing physical exercise to enhance blood flow Performing constant screening Performing detoxification and burning fats
Condition/procedures Performing family medical history Checking if the MI was inherited from the lineage Taking drugs to remove the clots

In conclusion, hospitals are striving to meet the standards set by CMS. Centers for Medicare and Medicaid Services has penalized several hospitals that violate the 30-day readmission law. As a result, healthcare facilities have adopted strategies to prevent patients’ readmission, especially those suffering from acute myocardial infarction (MI). They have adopted Transitioning plans to ensure that patients can continue their medication at their homes without being readmitted. MI patients often experience when they are transferred to their homes to seek medical attention.


Albert, N. M. (2016). A systematic review of transitional care strategies to reduce rehospitalization in patients with heart failure. Heart & Lung, 45(2), 100-113. Web.

Hocutt, P. L. (2017). Transitional care coach program evaluation at a Southwest Urban Medical Center. The University of Arizona. Web.

Mehta, L. S., Beckie, T. M., DeVon, H. A., Grines, C. L., Krumholz, H. M., Johnson, M. N., Johnson, K. J., Lindley, V. V., Wang, T. Y., Watson, K. E., & Wenger, N. K. (2016). Acute myocardial infarction in women: a scientific statement from the American Heart Association. Circulation, 133(9), 916-947. Web.

Piepoli, M. F., Corrà, U., Dendale, P., Frederix, I., Prescott, E., Schmid, J. P., Cupples, C. D., Doherty, P., Giannuzzi, P., Graham, I., Hansen, T. B., Jennings, C., Landmesser, U., Marques-Vidal, P., Vrints, C., Walker, D., Bueno, H., Fitzsimons, D., & Pelliccia, A. (2017). Challenges in secondary prevention after acute myocardial infarction: A call for action. European Journal of Cardiovascular Nursing, 16(5), 369-380. Web.

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"The Patient With Acute Myocardial Infarction: Transition Plan." OctoStudy, 4 June 2022, octostudy.com/the-patient-with-acute-myocardial-infarction-transition-plan/.

1. OctoStudy. "The Patient With Acute Myocardial Infarction: Transition Plan." June 4, 2022. https://octostudy.com/the-patient-with-acute-myocardial-infarction-transition-plan/.


OctoStudy. "The Patient With Acute Myocardial Infarction: Transition Plan." June 4, 2022. https://octostudy.com/the-patient-with-acute-myocardial-infarction-transition-plan/.


OctoStudy. 2022. "The Patient With Acute Myocardial Infarction: Transition Plan." June 4, 2022. https://octostudy.com/the-patient-with-acute-myocardial-infarction-transition-plan/.


OctoStudy. (2022) 'The Patient With Acute Myocardial Infarction: Transition Plan'. 4 June.

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