Predischarge, postdischarge and bridging transitions scope of practice (SOP) of APNs within APN-led models of care within clinical settings
rStudy | Allen et al59 | Hirschman and Bixby60 | Litaker et al62 | Li et al61 | Zimmerman 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.