Table 2

Predischarge, postdischarge and bridging transitions scope of practice (SOP) of APNs within APN-led models of care within clinical settings

rStudyAllen et al59Hirschman and Bixby60Litaker et al62Li et al61Zimmerman et al63
Predischarge SOP
Screening, assessment, comprehensive needs assessment
Patient-centred care, Individualised care and care planning
Education, counselling and coaching
Collaboration
Medication management, adjustment, education, reconciliation
Management, monitoring, action planning and red flag identification
Coordination
Documentation
Postdischarge SOP
Assessment
Individualised care, care planning and treatment regimes ✓ ✓ ✓ ✓
Collaboration
Medication management, reconciliation, adjustment, monitoring, prescribing
Management, monitoring, action planning and red flag identification ✓ ✓ ✓ ✓
Follow-up care:
Home visits
Telephone calls
Office visits
By mail
Education, counselling and coaching
Documentation
Bridging transition SOP
Transition coach
Patient-centred transitions instructions
  • APN, advanced practice nurse.