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NURS FPX 6614 Defining a Gap in Practice Executive Summary Paper Example

NURS FPX6614 Assessment 1 Defining a Gap in Practice Executive Summary

NURS FPX 6614 Defining a Gap in Practice Executive Summary Paper Assignment Brief

Course: NURS-FPX6614 Structure and Process in Care Coordination

Assignment Title: NURS FPX6614 Assessment 1 Defining a Gap in Practice Executive Summary

Assignment Overview

In this assignment, you will develop an executive summary presenting a key gap in practice related to care coordination for a specific population. This executive summary will include a PICOT question that identifies the gap, analysis of potential services and resources for care coordination, assessment of the type of care coordination intervention needed, and explanation of the planning of the intervention and expected outcomes. The goal is to inform decision makers and stakeholders about the identified gap and propose evidence-based strategies for addressing it.

Understanding Assignment Objectives

This assignment aims to assess your ability to analyze clinical priorities for specific populations, evaluate potential services and resources available for care coordination, create effective interprofessional collaboration strategies, propose evidence-based care coordination processes, and communicate findings clearly and effectively.

The Student’s Role

As a student, your role is to critically examine the existing literature and identify a gap in care coordination practice relevant to a specific population. You will then formulate a PICOT question to address this gap and develop an executive summary outlining the key elements necessary to inform decision making and action.

Competencies Measured

This assignment measures several key competencies:

• Analyze clinical priorities for a specific population to effectively influence health outcomes with a care coordination process.
• Evaluate potential services and resources available for specific populations that are part of the care coordination process.
• Create an effective interprofessional collaboration strategy for improving population health care outcomes as a care coordination process.
• Propose a care coordination process for a specific population using the scope and standards of practice for care coordination.
• Communicate effectively as a scholar-practitioner to inform best practice.

NURS FPX 6614 Defining a Gap in Practice Executive Summary Paper Example

Introduction

Hypertension, a pervasive health concern affecting millions worldwide, poses significant risks, including heart disease and stroke (CDC, 2020). Its prevalence is particularly pronounced among obese individuals, exacerbating the condition and necessitating tailored interventions (Oparil et al., 2018). Lifestyle modifications and medication management are central to hypertension treatment, with care coordination playing a pivotal role in optimizing patient outcomes. This executive summary seeks to explore the comparative effectiveness of lifestyle changes versus medications in managing hypertension among overweight patients while emphasizing the importance of care coordination in treatment decisions. By examining existing knowledge gaps, defining key interventions, and outlining expected outcomes, this summary aims to inform evidence-based strategies for addressing hypertension in the context of obesity.

Clinical Priorities for Overweight Hypertensive Patients

Obesity, as defined by the World Health Organization (WHO, 2021), refers to having 20% more weight than the ideal weight. This condition is linked to various adverse health outcomes, including hypertension, Type II Diabetes mellitus, coronary artery disease, heart failure, kidney disease, and hyperlipidemia (WHO, 2021). Not only does obesity cause hypertension, but it also exacerbates its symptoms. Overweight hypertensive individuals often experience hormonal imbalances, abnormalities in their sympathetic nervous system, and kidney function issues. The accumulation of visceral fat in obese individuals increases abdominal pressure, placing additional strain on the cardiovascular system (CVS) (Chrysant, 2019). This strain contributes to uncontrolled or persistent hypertension, leading to symptoms such as dizziness, nosebleeds, headaches, vision changes, chest pain, and muscle tremors (Chrysant, 2019). Therefore, it is imperative to develop effective healthcare strategies, including medication regimens or lifestyle modifications, to help overweight patients manage their hypertensive symptoms.

Care coordination emerges as a critical tool for healthcare providers in assisting overweight hypertensive individuals with managing their hypertension symptoms. A streamlined care coordination process facilitates easier communication between patients and their healthcare team members, including physicians, nutritionists, pharmacists, and nurses (Karam et al., 2021). This team-based strategy aims to involve patients in their own care, emphasizing collaboration among healthcare team members (Karam et al., 2021).

In-depth Analysis or Knowledge Gap

While medications are commonly prescribed for hypertension management, they may lead to adverse effects and medication non-adherence. Gebreyohannes and colleagues (2019) highlight the potential exacerbation of hypertension in obese individuals due to medication side effects. Additionally, the adverse effects associated with antihypertensive drugs hinder patient adherence to medication regimens (Gebreyohannes et al., 2019). In another study by Cosimo Marcello et al. (2019), it is proposed that adopting low-salt diets and engaging in regular exercise could aid obese individuals in managing their hypertension symptoms effectively. By embracing healthy eating habits and incorporating physical activity into their daily routines, patients can safely lose weight and maintain stable blood pressure levels (Cosimo Marcello et al., 2019). However, there remains a gap in understanding the comparative effectiveness of lifestyle modifications versus medications in overweight hypertensive patients.

PICOT Question

The PICOT question aims to assess the effectiveness of lifestyle modifications compared to antihypertensive medications in achieving low blood pressure within a six-month period for overweight adults with hypertension.

• Population: Overweight adults
• Intervention: Lifestyle modifications
• Comparison: Lifestyle modifications versus medications
• Outcome: Low blood pressure
• Time: Six months

Explanation of the Selected Gap

According to Alsaigh et al. (2019), proper care planning is crucial to mitigate the potentially fatal consequences of hypertension. Lifestyle changes play a significant role in reducing blood pressure and delaying the onset of hypertension in otherwise healthy individuals. Alsaigh et al. (2019) suggest that patients with hypertension should prioritize lifestyle adjustments before considering pharmacologic therapy. Care coordinators play a vital role in educating overweight hypertensive patients and assessing their understanding through open-ended questions. Guiding patients on behavioral adjustments to achieve desired outcomes constitutes a critical aspect of the care coordinator’s role (Karam et al., 2021).

At the regional level, the Joint National Committee (JNC) recommends lifestyle modifications for hypertensive patients over a six-month period. These modifications include increased physical activity, dietary changes focusing on obesity, reduced salt intake, and limited alcohol consumption (de la Sierra, 2019). The PREMIER trial, the largest clinical trial conducted in the US, examined the impact of lifestyle changes on hypertension management. Results indicated that weight loss, increased physical activity, and dietary improvements effectively managed hypertension without medication (Mahmood et al., 2019). However, Kebede et al. (2022) note that while both lifestyle modifications and medications can lower blood pressure within six months, medications may manifest side effects during this period.

Services and Resources for Care Coordination

Resources

Healthcare teams have various tools at their disposal to educate obese hypertensive patients about lifestyle modifications, including social media messages, fact sheets, and handouts.

Potential Services

In many healthcare facilities, care teams comprise nurses, physicians, pharmacists, information technology specialists, and hospital administrators. Nurses, acting as care coordinators, play a vital role in educating obese hypertensive patients about adopting healthy lifestyle choices. Furthermore, the entire team can leverage telehealth services to monitor patients’ adherence to prescribed lifestyle changes (Volterrani & Sposato, 2019).

Barriers

Despite the benefits of care coordination, several obstacles hinder its effectiveness. One such obstacle is the lack of patient trust in healthcare professionals or their inability to engage in self-management practices, which compromises coordination efforts (Heinert et al., 2019). Additionally, challenges with health information technology implementation may impede the successful execution of care coordination strategies. Limited resources also pose a barrier to effective care coordination. Moreover, the beliefs of obese hypertensive patients, their motivation levels, and the presence of depression can further complicate the care coordination process (Heinert et al., 2019).

The Type of Care Coordination Intervention

Care coordination, as outlined by the Agency for Healthcare Research and Quality (AHRQ), relies on five fundamental pillars. These pillars encompass teamwork between staff and patients, effective utilization of health information technology, care, and medication management, and prioritizing patient-centered care (Agency for Healthcare Research and Quality, 2018).

Specific and Practical Approach

To educate obese hypertensive patients about necessary lifestyle adjustments, healthcare professionals should employ the Chronic Care Model, as suggested by Pilipovic-Broceta et al. (2018). This entails fostering accountability and responsibility within the organization. Regular meetings involving key stakeholders, including nurses, physicians, nutritionists, pharmacists, and information technologists, are essential for effective communication and knowledge exchange. Through these meetings, patient needs and goals can be discussed, and evidence-based care plans can be developed (Pilipovic-Broceta et al., 2018). Post-planning, stakeholders must implement the care plan, support and guide patients in achieving self-management goals, and conduct follow-up assessments (Agency for Healthcare Research and Quality, 2018).

Supporting Collaborative Care Strategies

Healthcare professionals and nurses should prioritize lifestyle modifications as the primary intervention strategy to support collaborative care. Obese hypertensive patients face heightened risks if appropriate lifestyle changes are not adopted (Csige et al., 2018). Optimal health outcomes and minimal side effects are more achievable through adherence to an exercise regimen and a healthy diet than reliance solely on medication. Achieving these goals necessitates collaborative efforts from all stakeholders.

Example Strategies

Kreps (2018) proposed an effective plan for interdisciplinary teamwork to enhance health outcomes. The study recommends the involvement of healthcare providers, administrators, nutritionists, information technology specialists, and consumers in the care process. Holding team meetings facilitates the sharing of relevant patient information among all involved parties (Kreps, 2018). Establishing norms for group interactions, distributing responsibilities, encouraging diverse perspectives, and integrating new information are also critical aspects of successful teamwork.

Specific Nursing Diagnosis

The identified nursing diagnosis is hypertension induced by obesity. Overweight individuals face an elevated risk of developing hypertension, with obesity exacerbating the condition further. Obesity contributes to physiological changes that may lead to or worsen hypertension. Failure to manage weight through lifestyle adjustments can lead to severe hypertension-related complications, including cardiovascular disease, kidney failure, and vision impairment (Shariq & McKenzie, 2020). Nurses play a vital role in educating obese hypertensive patients about lifestyle modifications to manage their condition effectively and restore blood pressure to normal levels (Shariq & McKenzie, 2020).

Planning of the Intervention and Anticipated Results

Care coordinators play a pivotal role in organizing regular meetings to set goals and objectives for obese hypertensive individuals, formulate comprehensive care plans, and garner support from all key stakeholders. The nutritionist will collaborate with patients to devise effective diet plans aimed at weight loss and hypertension management. Meanwhile, the physiotherapist will tailor exercise regimens specifically for obese patients to address their hypertensive symptoms. IT specialists will aid in implementing health information technologies, such as the HIPAA-compliant text messaging platform, streamlining the care coordination process (Liu et al., 2019). Additionally, telehealth services will assist nurses in educating patients about lifestyle modifications and monitoring their adherence to prescribed dietary and exercise routines (Liu et al., 2019). Following the planning phase, the implementation phase commences, during which nurses and physicians will educate obese hypertensive patients on the superiority of lifestyle modifications over medication. Telehealth platforms can facilitate patient education and compliance monitoring for prescribed lifestyle changes.

Expected Outcomes

Individuals with obesity and hypertension are expected to derive greater benefits from this approach upon understanding how lifestyle changes can outweigh the advantages of medication. Furthermore, effective collaboration among healthcare providers is anticipated, which is crucial for achieving optimal health outcomes.

Assumptions

This analysis operates under the assumption that healthcare team efforts in care coordination will empower overweight hypertensive patients to adopt necessary lifestyle modifications. These changes are deemed more favorable than medication therapy due to the side effects associated with medications, which can hinder patient adherence.

Conclusion

In conclusion, addressing hypertension in overweight individuals requires a multifaceted approach that integrates both lifestyle modifications and medication management while leveraging effective care coordination strategies. The significance of lifestyle changes, including dietary adjustments and regular exercise, cannot be overstated in managing hypertension symptoms in this population. However, the comparative effectiveness of lifestyle modifications versus medications remains a gap in practice, underscoring the need for further research to inform evidence-based interventions. Care coordination emerges as a critical tool in facilitating patient education, promoting adherence to prescribed regimens, and fostering collaborative efforts among healthcare providers. By prioritizing patient-centered care and leveraging health information technology, healthcare teams can optimize outcomes for overweight hypertensive patients, ultimately improving their overall health and well-being.

References

Agency for Healthcare Research and Quality. (2018). Care coordination. https://www.ahrq.gov/topics/care-coordination/index.html

CDC. (2020). High blood pressure. https://www.cdc.gov/bloodpressure/index.htm

Chrysant, S. G. (2019). Pathophysiology of obesity hypertension. Hypertension Research, 42(8), 1235–1246.

Cosimo Marcello, C., et al. (2019). Lifestyle interventions to reduce cardiovascular risk in hypertension: Does it work? High Blood Pressure & Cardiovascular Prevention, 26(2), 97–105.

de la Sierra, A. (2019). Hypertension and lifestyle modification. Hypertension Research, 42(8), 1235–1246.

Gebreyohannes, E. A., et al. (2019). Adverse effects and non-adherence to antihypertensive medications in university community-based clinic settings. Clinical Hypertension, 25(1), 1–10.

Heinert, S., et al. (2019). Barriers to care coordination: Lessons learned from successful programs. Journal of General Internal Medicine, 34(1), 75–78.

Karam, S. G., et al. (2021). The role of care coordination in hypertension management: A systematic review. Journal of Hypertension, 39(5), 883–892.

Kebede, T. M., et al. (2022). Lifestyle modification versus antihypertensive medication for blood pressure control in overweight hypertensive patients: A randomized controlled trial. American Journal of Hypertension, 35(3), 309–316.

Kreps, G. L. (2018). The significance of interdisciplinary teamwork and collaboration in achieving public health goals. American Journal of Public Health, 108(S3), S230–S231.

Liu, Y., et al. (2019). The role of telehealth in hypertension management: A review. Telemedicine and e-Health, 25(1), 3–13.

Mahmood, S. S., et al. (2019). Lifestyle modification for lowering blood pressure: A systematic review and meta-analysis. The Journal of Clinical Hypertension, 21(8), 1154–1161.

Oparil, S., et al. (2018). 2018 practice guidelines for the management of hypertension in the community: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension, 71(6), e13–e115.

Pilipovic-Broceta, N., et al. (2018). Implementing the Chronic Care Model in clinical practice: A step-by-step approach. International Journal of Integrated Care, 18(1), 1–5.

Shariq, U., & McKenzie, K. (2020). Obesity and hypertension: A comprehensive review of the evidence. Journal of Hypertension, 38(6), 999–1014.

Volterrani, L., & Sposato, B. (2019). Role of telehealth in care coordination and management of chronic diseases. Future Cardiology, 15(6), 415–418.

WHO. (2021). Obesity and overweight. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

Detailed Assessment Instructions for the NURS FPX 6614 Defining a Gap in Practice Executive Summary Paper Assignment

Description

Assessment 1 Instructions: Defining a Gap in Practice: Executive Summary

Develop a PICOT question that defines a gap in practice and write a 2-3 page executive summary presenting the key elements that decision makers will need to make decisions.

Introduction

Note: Complete the assessments in this course in the order in which they are presented.

It is important to define your ideas clearly and precisely to help develop and sustain stakeholder buy-in with any project being created to improve outcomes. Using a  PICOT  gives the reader a clear idea of your improvement project in one succinct sentence. Another important communication tool is written for the administrative stakeholders in the form of an executive summary. The executive summary provides a brief and precise narrative of what you want to expedite for your improvement project. Executive summaries are commonly associated with business plans, marketing plans, evaluation studies, and other materials that are created to guide decision making and action. As an actionable document, the executive summary is meant to set out the key elements that a decision maker will need in order to make decisions and, as important, to justify those decisions to those to whom the decision maker is responsible.

Preparation

Read the following:

• American Academy of Ambulatory Care Nursing. (2016). Scope and standards of practice for registered nurses in care coordination and transition management .

. Standard 1: Assessment.

. Standard 2: Nursing Diagnoses.

. Standard 3: Outcomes Identification.

. Standard 4: Planning.

. Standard 5a: Coordination of Care.

. Standard 5b: Health Teaching and Health Promotion.

Assessment Summary

Develop a PICOT question that defines a gap in practice related to a specific population at the organizational, regional, or national level for care coordination. Write a 2–3 page executive summary (not including the title and reference pages). Include 4–6 scholarly sources on the reference page. You may use the  Evidence-Based Practice in Nursing & Health Sciences: PICOT Question Process  library guide to help direct your research.

You are encouraged to formulate a PICOT question based on a clinical question from your field of expertise or reflective of a specialization or strong area of career interest.

Grading Criteria

The numbered instructions outlined below correspond to the grading criteria in the Defining a Gap in Practice: Executive Summary Scoring Guide, so be sure to address each point. You may also want to review the performance-level descriptions for each criterion to see how your work will be assessed.

1. Analyze clinical priorities for a specific population to effectively influence health outcomes with a care coordination process.
2. Apply a PICOT question to a gap in practice at the organizational, regional, or national level for care coordination.

. What is the PICOT question?

. Provide and explanation of the selected gap.

• Evaluate the potential services and resources for care coordination that are currently available for use with the selected population.
• Assess the type of care coordination intervention that would best fit to enhance evidence-based practice.
• Summarize the selected nursing diagnosis to support the strategy for collaborative care to present to the interprofessional team to develop stakeholder understanding.

. Present an assessment of the issue to start the process.

• Explain the planning of the intervention and expected outcomes you want to achieve for the care coordination process using the scope and standards of practice for care coordination.

. What are the planning steps for the intervention?

. What expected outcomes you want to achieve?

• Write content clearly and logically, with correct use of grammar, punctuation, and mechanics.

The audience for this presentation is an interprofessional team (including people in the care coordination process and leadership who are approving the process). Your objective is to develop stakeholder understanding and acceptance.​​​​

Additional Requirements

• Written communication: Write clearly, accurately, and professionally, incorporating sources appropriately.
• APA guidelines: Resources and citations are formatted according to current APA style and format. When appropriate, use APA-formatted headings. See Evidence and APA for more information.
• Font and font size: Times Roman, 12 point.

Portfolio Prompt: You may choose to save your gap analysis to your ePortfolio.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

• Competency 1: Analyze clinical priorities for a specific population that can influence health outcomes in the care coordination process.

. Analyze clinical priorities for a specific population to effectively influence health outcomes with a care coordination process.

. Apply a PICOT question to a gap in practice at the organizational, regional, or national level for care coordination.

• Competency 2: Evaluate potential services and resources available for specific populations that are a part of the care coordination process.

. Evaluate the potential services and resources for care coordination that are currently available for use with the selected population.

• Competency 3: Create an effective interprofessional collaboration strategy for improving population health care outcomes as a care coordination process.

. Assess the type of care coordination intervention that would best fit to enhance evidence-based practice.

. Summarize the selected nursing diagnosis to support the strategy for collaborative care to present to the interprofessional team to develop stakeholder understanding.

• Competency 4: Propose a care coordination process for a specific population using the scope and standards of practice for care coordination.

. Explain the planning of the intervention and expected outcomes you want to achieve for the care coordination process using the scope and standards of practice for care coordination.

• Competency 5: Communicate effectively as a scholar-practitioner to inform best practice.

. Write content clearly and logically, with correct use of grammar, punctuation, and mechanics.

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NURS FPX 6612 Patient Discharge Care Planning Paper Example

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

NURS FPX 6612 Patient Discharge Care Planning Paper Assignment Brief

Course: NURS-FPX6612 Health Care Models Used in Care Coordination

Assignment Title: NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Assignment Overview

The Patient Discharge Care Planning Paper assignment in NURS FPX 6612 aims to analyze key issues related to the development of an effective discharge care plan for a hypothetical patient. This assignment underscores the significance of health information technology (HIT) in optimizing care coordination, data reporting, and the overall efficacy of the discharge process.

Understanding Assignment Objectives

The primary objective of this assignment is to demonstrate the student’s proficiency in applying care coordination models, understanding the relationship between care coordination and evidence-based data, utilizing health information technology, and communicating effectively with diverse audiences in an academic format.

The Student’s Role

As a student enrolled in NURS FPX 6612, your role is to assume the position of a senior care coordinator responsible for overseeing a patient’s care. You will lead the discussion on patient’s case during an interdisciplinary team meeting, focusing on the role of informatics in effective discharge care planning. Your task involves analyzing key issues related to HIT support, data reporting, and electronic health record (EHR) data collection to facilitate patient’s transition from the hospital to their home environment.

You Can Also Check Other Related Assessments for the NURS-FPX6612 Health Care Models Used in Care Coordination Course:

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures Presentation Example

NURS FPX 6612 Assessment 2 Quality Improvement Proposal Example

NURS FPX 6612 Assessment 4 Cost Savings Analysis Example

NURS FPX 6612 Patient Discharge Care Planning Paper Example

Introduction

The focus of this assessment is on the discharge care planning for Marta Rodriguez, who underwent extensive treatment after a severe car accident while on her way to college. Marta spent four weeks in the trauma center, receiving multiple surgeries and antibiotic therapy. As the senior care coordinator, I will lead the discussion on Marta’s discharge plans with the interdisciplinary team. This analysis highlights the importance of health information technology (HIT) in optimizing care coordination, data reporting, and the overall effectiveness of Marta’s transition from the hospital to her home environment.

Longitudinal, Patient-Centered Care Plan

To ensure Marta Rodriguez receives comprehensive, patient-centered care, the interdisciplinary team will harness various components of health information technology (HIT). Electronic health records (EHRs), secure messaging platforms, telehealth technology, and medication reconciliation tools are pivotal in this endeavor (Schwab et al., 2021; Flickinger et al., 2022; Chowdhury et al., 2020). EHRs provide real-time access to Marta’s medical records, facilitating the development of a holistic care plan. Secure messaging platforms enable seamless communication among team members, ensuring timely updates on Marta’s condition, appointments, and medication schedules. Telehealth technology facilitates remote monitoring of Marta’s vital signs, aiding in the early detection of complications. Additionally, medication reconciliation tools ensure accurate medication lists, reducing the risk of errors.

To mitigate the risk of readmission within 48 hours post-discharge, comprehensive education, support, and follow-up care for Marta are paramount (Oksholm et al., 2023). HIT elements, particularly telehealth technology, enable continuous monitoring of Marta’s progress, allowing for timely interventions in case of complications. Secure messaging platforms serve as a conduit for delivering crucial information regarding medication adherence and follow-up appointments.

Furthermore, leveraging HIT elements promotes communication and collaboration among team members, enhancing care coordination for Marta. EHRs serve as a centralized repository of Marta’s health information, ensuring all team members have access to pertinent data. This cohesive approach streamlines care delivery, minimizing redundancies, and maximizing efficiency. Through the strategic use of HIT elements, the interdisciplinary team can deliver a patient-centered, coordinated care plan tailored to Marta’s unique needs.

Data Reporting

Data reporting is integral to optimizing patient care across various dimensions, including coordination, management, efficiency, and innovation within healthcare. Specifically tailored data reporting for patients like Marta Rodriguez holds immense potential to elevate the quality of care and expedite her recovery journey. Firstly, it facilitates seamless care coordination among interdisciplinary team members by offering a unified view of Marta’s condition and progress (Brooks et al., 2020). Real-time access to data on medication adherence, vital signs, and symptoms empowers the team to collaboratively devise personalized care plans, thus minimizing risks of complications or readmissions.

Furthermore, data reporting aids in fine-tuning care management strategies by pinpointing areas necessitating additional support or intervention. By analyzing data on pain levels, mobility, and nutritional status, the team can proactively address emerging issues, thereby optimizing Marta’s path to recovery. Additionally, data reporting serves as a catalyst for interprofessional innovation by providing insights into Marta’s preferences and cultural background, fostering tailored care delivery (Leslie & Paradis, 2018). This patient-centric approach fosters trust and rapport between Marta and her care team, ultimately enhancing health outcomes.

To uphold data integrity, stringent validation protocols and regular audits must be implemented. Ensuring data accuracy, completeness, and timeliness empowers the team to make well-informed clinical decisions confidently. Moreover, aligning data reporting practices with evidence-based guidelines guarantees that interventions are rooted in best practices, thus elevating the overall quality of care provided to Marta.

Client Records Influencing Health Outcomes

Client records play a pivotal role in influencing health outcomes by providing valuable data that guides patient care decisions. Marta Rodriguez’s case exemplifies how health information technology (HIT) can be utilized by healthcare teams to gather, analyze, and disseminate client record data, thereby enhancing patient care and results. Let’s explore how insights derived from patient records positively impact health outcomes and how interdisciplinary teams can synchronize their efforts through collaborative HIT utilization.

HIT facilitates the collection and analysis of patient record data by interdisciplinary teams, enabling the identification of trends, patterns, and care gaps (Leslie & Paradis, 2018). For instance, Marta’s records offer insights into her medical history, medication regimen, and current health status, empowering the team to devise a customized care plan tailored to her specific needs. Moreover, HIT aids in the early detection of potential risks like adverse drug reactions or post-surgery complications, allowing for prompt interventions to prevent unfavorable health outcomes.

Additionally, HIT fosters seamless care coordination among interdisciplinary team members. By sharing information extracted from client records, team collaboration in patient care management is significantly enhanced. HIT tools such as Electronic Health Records (EHRs) and secure messaging platforms facilitate real-time communication among team members, ensuring everyone remains updated on the latest patient information. This reduces the risk of errors and miscommunications, ultimately contributing to improved health outcomes for the patient.

To effectively synthesize their findings, interdisciplinary team members must engage in cohesive collaboration to develop a unified understanding of the patient’s care requirements. This necessitates transparent communication, shared objectives, and a collective commitment to achieving common goals (Rawlinson et al., 2021). HIT tools serve as facilitators of this collaborative approach by providing a centralized platform for data access and exchange among team members. This ensures that all members possess a comprehensive view of the patient’s care needs, enabling them to deliver holistic care addressing all aspects of the patient’s health.

Conclusion

In conclusion, Marta Rodriguez’s discharge care plan requires a holistic, patient-centered approach supported by health information technology (HIT). The interdisciplinary team must leverage HIT elements such as electronic health records (EHRs), telehealth technology, and secure messaging platforms to facilitate seamless communication, data sharing, and care coordination. Effective data reporting is crucial in shaping care management, clinical efficiency, and interprofessional innovation, ensuring that Marta receives personalized, evidence-based care. By harnessing client records and maximizing the potential of HIT tools, interdisciplinary teams can optimize health outcomes and promote Marta’s successful transition from the hospital to her home environment.

References

Brooks, R. G., Steele, S. R., & Wiersma, M. L. (2020). Data reporting: Essential to health care value and quality. Journal of the American College of Surgeons, 231(4), 485–490.

Chowdhury, M. R., Rahman, T., & Khandakar, A. (2020). A review of the state-of-the-art telehealth systems enabling remote monitoring of vital signs—Current status and future challenges. IEEE Reviews in Biomedical Engineering, 13, 107–124.

Flickinger, T. E., Surian, D., Uezono, Y., Kay, A., Amato, M. S., & Bokarius, A. (2022). Longitudinal implementation outcomes and clinical benefits of a secure messaging platform in a large integrated health system. Journal of Medical Internet Research, 24(1), e32123.

Leslie, M., & Paradis, E. (2018). Grooving to the same beat: Healthcare team interactions and adaptive rhythm. Medical Education, 52(6), 590–600.

Oksholm, T., Sandvik, M., & Wangensteen, S. (2023). Factors influencing unplanned readmissions: A qualitative study of hospitalized patients’ experiences. BMC Health Services Research, 23(1), 31.

Rawlinson, F., Morrison, Z., Dhaliwal, N., & Kalra, D. (2021). Self-assessment in health professional education: A meta-synthesis of qualitative research. Medical Teacher, 43(1), 93–103.

Schwab, P., Wilcox, A., Bair, A., Watson, J., Reid, M. W., & Coffey, C. (2021). Creating real-time enhanced patient information displays in the electronic health record: A case study. JAMIA Open, 4(3), ooab072.

Detailed Assessment Instructions for the NURS FPX 6612 Patient Discharge Care Planning Paper Assignment

Description

Assessment 3 Instructions: Patient Discharge Care Planning Paper Assignment

PRINT

• Patient Discharge Care Planning
  • Prepare a written analysis of key issues, 6–7 pages in length, applicable to the development of an effective patient discharge care plan.
    The Institute of Medicine’s 2000 report To Err Is Human: Building a Safer Health System identified health information technology (HIT) as one avenue to explore to reduce avoidable medical errors. As a result of the IOM report and suggestions for patient advocacy groups, health care organizations are encouraged to act by utilizing HIT to improve patient quality and safety.

SHOW LESS

• • Health care organizations determine outcomes by how patient information is collected, analyzed, and presented, and nurse leaders are taking the lead in using HIT to bridge the gaps in care coordination. This assessment provides an opportunity for you to analyze the effects of HIT support, data reporting, and EHR data collection on effective care planning.
    By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
  • Competency 1: Apply care coordination models to improve the patient experience, promote population health, and reduce costs. 
    • Explain how HIT can be used to provide a longitudinal, patient-centered care plan across the continuum of care.
  • Competency 2: Explain the relationship between care coordination and evidence-based data. 
    • Describe ways in which data reporting specific to client behaviors can shape care coordination, care management, clinical efficiency, and interprofessional idea development.
  • Competency 3: Use health information technology to guide care coordination and organizational practice. 
    • Explain how information collected from client records can be used to positively influence health outcomes.
  • Competency 4: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards. 
    • Write clearly and concisely, using correct grammar and mechanics.
    • Support main points, claims, and conclusions with relevant and credible evidence, correctly formatting citations and references using APA style.
  • Reference
    Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press.
    Competency Map
    CHECK YOUR PROGRESS
  • Use this online tool to track your performance and progress through your course.
• Toggle DrawerResourcesHealth Informatics
  • Mosier, S., & Englebright, J. (2019). The first step toward reducing documentation: Defining ideal workflows. CIN: Computers, Informatics, Nursing, 37(2), 57–59.
  • Yang, Y., Bass, E. J., Bowles, K. H., & Sockolow, P. S. (2019).Impact of home care admission nurses’ goals on electronic health record documentation strategies at the point of care. CIN: Computers, Informatics, Nursing, 37(1), 39–46.
  • SHOW LESSWriting Resources
    You are encouraged to explore the following writing resources. You can use them to improve your writing skills, and as source materials for seeking answers to specific questions.
  • APA Module.
  • Academic Honesty & APA Style and Formatting.
  • APA Style Paper Tutorial [DOCX].
  • Capella Resources
  • ePortfolio.

Research Resources

You may use other resources of your choice to prepare for this assessment; however, you will need to ensure that they are appropriate, credible, and valid. The MSN-FP6612: Emerging Health Care Models and Care Coordination Library Guide can help direct your research. The Supplemental Resources and Research Resources, both linked from the navigation menu in your courseroom, provide additional resources to help support you.
As you review these resources, you may want to consider the following questions:

• • How are nurse leaders taking the lead in using HIT to bridge the gaps in care coordination?
  • Why is the consistent use of common HIT terminology important?
  • What is the impact of data reporting in determining health outcomes, the effectiveness of health education, and the ability to predict client behaviors?
• Assessment Instructions

• Preparation
  Marta Rodriguez, a student, recently moved from New Mexico to Nevada to live with her aunt and uncle and was enrolled as a freshman in college. While attending her first semester, Marta was involved in a hit-and-run car accident. She was transported to the nearest shock trauma center where she spent the next four weeks undergoing multiple surgeries and antibiotic treatment for a systemic infection. Spanish is Marta’s first language and English is her second. Marta has a student health insurance plan.
  You are the senior care coordinator overseeing Marta’s care. You will be presenting her case to the interdisciplinary team members who are caring for Marta at an upcoming meeting to consider key aspects of a successful and safe discharge care plan for her. You are expected to lead the discussion, focusing on the role of informatics in effective discharge care planning, and have decided to prepare an analysis of key issues for team members to consider, which you will distribute to the attendees for review prior to the meeting.

Note:

• Remember that you can submit all or a portion of your draft to Smarthinking for feedback before you submit the final version of this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.
  Requirements
  Analyze key issues for consideration at the discharge planning meeting. Determine the effects of HIT support, data reporting, and EHR data collection on effective care planning.
  Use the following template for your written analysis:
  • APA Style Paper Template [DOCX].
  • Analyzing Key Issues
    The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your analysis addresses each point, at a minimum. You may also want to read the Patient Discharge Care Planning Scoring Guide to better understand how each criterion will be assessed.
  • Explain how the interprofessional team will use HIT to provide a longitudinal, patient-centered care plan across the continuum of care that supports Marta in the discharge planning process.
    • What HIT elements will the team members use and why?
    • How can the interprofessional team members utilize the HIT elements to prevent a readmission of this patient 48 hours after being discharged?
    • How will the use of these elements support the coordination of care for this patient?
  • Describe at least three ways in which data reporting specific to client behaviors can shape care coordination, care management, clinical efficiency, and interprofessional innovation in care.
    • How would you evaluate the quality of the data?
  • Explain how information collected from client records can be used to positively influence health outcomes.
    • How will the interprofessional team members coordinate their individual findings in the collaborative use of HIT?
  • Write clearly and concisely, using correct grammar and mechanics.
    • Express your main points and conclusions coherently.
    • Proofread your writing to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your analysis.
  • Support main points, claims, and conclusions with relevant and credible evidence, correctly formatting citations and references using APA style.
    • Is your supporting evidence clear and explicit?
    • How or why does particular evidence support a claim?
    • Will your audience see the connection?
  • Additional Requirements
    Written Analysis Format and Length
    Format your written analysis using APA style:
  • Use theAPA Style Paper Template [DOCX]provided. Be sure to include:
    • A title page and references page. An abstract is not required.
    • A running head on all pages.
    • Appropriate section headings.
  • See also theAPA Style Paper Tutorial [DOCX]to help you in writing and formatting your analysis.
  • Your analysis should be 6–7 pages in length,not includingthe title page and references page.
  • Supporting Evidence
  • Cite at least eight sources of credible scholarly or professional evidence to support your analysis.
  • Apply APA formatting to all in-text citations and references.
  • Portfolio Prompt: You may choose to save your analysis to your ePortfolio.

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NURS FPX 6612 Triple Aim Outcome Measures Presentation Example

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures Presentation

Assignment Brief: NURS FPX 6612 Triple Aim Outcome Measures Presentation

Course: NURS-FPX6612 Health Care Models Used in Care Coordination

Assignment Title: NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures Presentation

Assignment Overview

In this assignment, you will develop a presentation consisting of 10–15 slides focusing on the Institute for Healthcare Improvement’s Triple Aim framework. Your presentation will explore how current and emerging healthcare models support the Triple Aim and how governmental regulatory initiatives and outcome measures can be utilized in the care coordination process to achieve the Triple Aim within a population.

Understanding Assignment Objectives

The purpose of this assignment is to demonstrate your understanding of the Triple Aim framework and its significance in improving population health, enhancing patient experience, and reducing healthcare costs. Additionally, you will analyze various healthcare models, explain their evolution and impact on healthcare quality, and describe governmental regulatory initiatives and outcome measures relevant to care coordination.

The Student’s Role

As a new case manager at Sacred Heart Hospital, your role is to deliver an evidence-based presentation to hospital leaders and clinical leadership teams. Your presentation will focus on modifying the care coordination process at Sacred Heart to achieve the Triple Aim within the hospital’s rural population.

You Can Also Check Other Related Assessments for the NURS-FPX6612 Health Care Models Used in Care Coordination Course:

NURS FPX 6612 Assessment 2 Quality Improvement Proposal Example

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning Example

NURS FPX 6612 Assessment 4 Cost Savings Analysis Example

NURS FPX 6612 Triple Aim Outcome Measures Presentation Example

Title Slide

• Title: Enhancing Care Coordination at Sacred Heart Hospital: Achieving Triple Aim Outcomes
• Presenter: Roseann Kimbrell
• Date: April 14, 2024

Speaker Notes:

• Good morning/afternoon, everyone. My name is Roseann Kimbrell, and I’ll be guiding you through our presentation today.
• Today’s presentation focuses on enhancing care coordination at Sacred Heart Hospital to achieve Triple Aim outcomes.
• We’ll delve into strategies to align our practices with the Triple Aim objectives, understand and compare healthcare models supporting Triple Aim, and discuss specific recommendations for improvement.

Purpose Slide

• Purpose: To inform Sacred Heart Hospital leadership about enhancing care coordination to achieve Triple Aim outcomes in the rural population served by the hospital.
• Align practices with Triple Aim objectives.
• Understand and compare healthcare models supporting Triple Aim.
• Focus on Patient-Centered Medical Home (PCMH) and Transitional Care models.

Speaker Notes:

• Our purpose today is clear: we want to ensure that Sacred Heart Hospital is on track to achieve the Triple Aim objectives within our rural community.
• To do this, we need to align our practices with the Triple Aim goals, understand how various healthcare models support these objectives, and focus on implementing strategies that will enhance care coordination.
• Throughout this presentation, we’ll primarily examine the Patient-Centered Medical Home (PCMH) and Transitional Care models as key approaches to achieving Triple Aim outcomes.

Definition of Triple Aim Outcome Measures Slide

• The Triple Aim: Simultaneously improving population health, enhancing patient care experience, and reducing per capita healthcare costs.
• Importance of efficient care coordination in achieving Triple Aim objectives.

Speaker Notes:

• Let’s start by defining what we mean by the Triple Aim. It’s a concept developed by the Institute for Healthcare Improvement (IHI) that focuses on three key objectives: improving population health, enhancing the patient care experience, and reducing per capita healthcare costs.
• Efficient care coordination is essential in achieving these objectives. It ensures that patients receive timely, appropriate care and that resources are used efficiently to improve health outcomes while minimizing costs.

Experience of Care/Patient Satisfaction Slide

• Patient experience crucial for adherence to treatment, care engagement, and health outcomes ((Kangovi et al., 2020).
• Improving communication, minimizing waiting times, and engaging patients in treatment plans enhance satisfaction.
• Better patient experience leads to improved health outcomes and compliance with treatment plans.

Speaker Notes:

• Patient satisfaction is not just a matter of convenience; it’s directly linked to health outcomes. When patients are satisfied with their care experience, they’re more likely to adhere to treatment plans, engage in their care, and ultimately achieve better health outcomes.
• Strategies such as improving communication, minimizing waiting times, and involving patients in their treatment plans can significantly enhance satisfaction levels and, consequently, health outcomes.

Improving Population or Community Health Slide

• Addressing community health needs by evaluating population data and formulating plans.
• Care coordination identifies high-risk patients and ensures appropriate care.
• Collaborate with community partners to address social determinants of health and execute preventive measures.

Speaker Notes:

• Improving community health requires a proactive approach that goes beyond individual patient care. It involves evaluating population data to identify trends, disparities, and unmet needs within the community.
• Care coordination plays a vital role in this process by identifying high-risk patients and ensuring they receive appropriate care to prevent adverse health outcomes.
• Collaborating with community partners to address social determinants of health and implementing preventive measures like immunizations and health screenings can further improve population health outcomes.

Decreasing Per Capita Costs Slide

• Goal: Decrease healthcare costs by improving care quality and minimizing waste.
• Efficient care coordination reduces hospital stays, unnecessary procedures, and readmissions.
• Addressing social determinants of health and promoting preventive care decrease healthcare costs.

Speaker Notes:

• One of the Triple Aim objectives is to reduce per capita healthcare costs, and efficient care coordination is key to achieving this goal.
• By improving care quality and minimizing waste, we can reduce unnecessary healthcare spending. This includes avoiding unnecessary hospital stays, procedures, and readmissions.
• Additionally, addressing social determinants of health and promoting preventive care can lead to significant cost savings by preventing the onset of costly chronic conditions and reducing the need for expensive treatments.

Analyzing Relationships Between Health Models and Triple Aim Slide

• Patient-Centered Medical Home (PCMH):
  • Philosophy: Comprehensive, coordinated, and patient-centered care.
  • Evolution: Incorporation of technology, patient engagement tools, and quality metrics.
  • Enhancements: Reduced hospital readmissions, improved chronic disease management, and patient/provider satisfaction.
• Transitional Care:
  • Philosophy: Support during care transitions to prevent adverse events.
  • Evolution: Incorporation of technology like telehealth for better communication.
  • Enhancements: Reduced readmissions, medication errors, and healthcare costs; improved patient satisfaction.

Speaker Notes:

• Let’s examine how two key healthcare models, the Patient-Centered Medical Home (PCMH) and Transitional Care, support the Triple Aim objectives.
• The PCMH model emphasizes comprehensive, coordinated, and patient-centered care. Over time, it has evolved to incorporate technology and patient engagement tools, leading to improvements in outcomes such as reduced hospital readmissions and better chronic disease management.
• Transitional Care, on the other hand, focuses on supporting patients during care transitions to prevent adverse events like readmissions and medication errors. Its evolution has involved incorporating telehealth technology for better communication, resulting in reduced healthcare costs and improved patient satisfaction.

Structure of Health Care Models Slide

• Patient-Centered Medical Home (PCMH):
  • Relies on electronic health records (EHRs) for real-time data access (McNabney et al., 2022).
  • Emphasizes evidence-based guidelines for quality care (Kaufman et al., 2018).
  • Utilizes interdisciplinary teams for comprehensive care delivery.
• Transitional Care:
  • Utilizes transitional care teams for coordination (Shahsavari et al., 2019).
  • Relies on evidence-based interventions during transitions (Fønss Rasmussen et al., 2021).
  • Incorporates technology like telehealth for enhanced communication.

Speaker Notes:

• Now, let’s delve into the structure of these healthcare models and how they contribute to gathering and evaluating evidence-based data.
• The PCMH model relies on electronic health records (EHRs) to provide real-time access to patient data, ensuring that healthcare providers have the information they need to make informed decisions.
• Additionally, the model emphasizes the use of evidence-based guidelines to ensure the delivery of high-quality care and employs interdisciplinary teams to provide comprehensive care to patients.
• Similarly, Transitional Care utilizes transitional care teams and evidence-based interventions to coordinate care during transitions, with a focus on leveraging technology like telehealth to enhance communication and ensure continuity of care.

Evidence-based Data Shaping Care Coordination Process Slide

• Care coordination relies on evidence-based data to identify patient needs and barriers to care (Kangovi et al., 2020).
• Data inform the development of care plans tailored to each patient’s unique needs.
• Use of evidence-based data promotes continuity of care and reduces medical errors.

Speaker Notes:

• The practice of care coordination in nursing heavily relies on evidence-based data to inform decision-making and improve patient outcomes.
• By using data, healthcare providers can identify patient needs, such as chronic conditions and social determinants of health, and develop care plans tailored to each patient’s unique needs and preferences.
• Additionally, evidence-based data promote continuity of care by ensuring that all healthcare providers have access to the same patient information, reducing the risk of medical errors and improving patient outcomes.

Governmental Regulatory Initiatives Slide

• Medicare Shared Savings Program (MSSP):
  • Incentivizes care coordination and quality improvement ((Bravo et al., 2022).
  • Encourages collaboration among healthcare providers.
• Hospital Readmissions Reduction Program (HRRP):
  • Penalizes hospitals with higher-than-expected readmission rates.
  • Encourages effective care coordination to reduce readmissions.

Speaker Notes:

• Governmental regulatory initiatives play a significant role in shaping the healthcare landscape and promoting care coordination.
• The Medicare Shared Savings Program (MSSP) incentivizes care coordination and quality improvement by rewarding healthcare providers who achieve cost savings while maintaining or improving quality.
• Similarly, the Hospital Readmissions Reduction Program (HRRP) penalizes hospitals with higher-than-expected readmission rates, encouraging effective care coordination to reduce readmissions and improve patient outcomes.

Process Improvement Recommendations to Stakeholders Slide

• Stakeholders:
  • Hospital administration, healthcare providers, patients, caregivers, and representatives from Vila Health.
• Anticipated Needs and Concerns:
  • Understanding the necessity of updating care coordination processes.
  • Impact of changes on workflow and resources.
• Response to Questions and Objections:
  • Assure stakeholders of minimal resource requirements and support for implementation.
  • Emphasize the importance of aligning practices with Triple Aim objectives.

Speaker Notes:

• As we move forward with improving our care coordination processes, it’s essential to engage stakeholders and address their needs and concerns.
• Stakeholders include hospital administration, healthcare providers, patients, caregivers, and representatives from Vila Health, all of whom play a crucial role in the success of our initiatives.
• We anticipate questions regarding the necessity of updating care coordination processes and concerns about the impact of changes on workflow and resources.
• In response, we will assure stakeholders of the minimal resource requirements for implementation and provide support to facilitate the transition. We’ll emphasize the importance of aligning our practices with the Triple Aim objectives to achieve better patient outcomes and enhance community health.

References Slide

Bravo, F., Levi, R., Perakis, G., & Romero, G. (2022). Care coordination for healthcare referrals under a shared‐savings program. Production and Operations Management. https://doi.org/10.1111/poms.13830

Fønss Rasmussen, L., Grode, L. B., Lange, J., Barat, I., & Gregersen, M. (2021). Impact of transitional care interventions on hospital readmissions in older medical patients: A systematic review. BMJ Open, 11(1), e040057. https://doi.org/10.1136/bmjopen-2020-040057

Kangovi, S., Mitra, N., Grande, D., Long, J. A., & Asch, D. A. (2020). Evidence-based community health worker program addresses unmet social needs and generates positive return on investment. Health Affairs, 39(2), 207–213. https://doi.org/10.1377/hlthaff.2019.00981

Kaufman, B. G., Spivack, B. S., Stearns, S. C., Song, P. H., O’Brien, E. C., & Kansagara, D. (2018). Impact of patient-centered medical homes on healthcare utilization. American journal of managed care, 24(5), 237-243.

M., S., & Chacko, A. M. (2021, January 1). 2 – Interoperability issues in EHR systems: Research directions (K. C. Lee, S. S. Roy, P. Samui, & V. Kumar, Eds.). ScienceDirect; Academic Press. https://www.sciencedirect.com/science/article/pii/B9780128193143000021

McNabney, M. K., Green, A. R., Burke, M., Le, S. T., Butler, D., Chun, A. K., Elliott, D. P., Fulton, A. T., Hyer, K., Setters, B., & Shega, J. W. (2022). Complexities of care: Common components of models of care in geriatrics. Journal of the American Geriatrics Society. https://doi.org/10.1111/jgs.17811

Ruediger, M., Kupfer, M., & Leiby, B. E. (2019). Decreasing re-hospitalizations and emergency department visits in persons with recent spinal cord injuries using a specialized medical home. The Journal of Spinal Cord Medicine, 44(2), 221–228. https://doi.org/10.1080/10790268.2019.1671075

Shahsavari, H., Zarei, M., & Aliheydari Mamaghani, J. (2019). Transitional care: Concept analysis using Rodgers’ evolutionary approach. International Journal of Nursing Studies, 99, 103387. https://doi.org/10.1016/j.ijnurstu.2019.103387

Detailed Assessment Instructions for the NURS FPX 6612 Triple Aim Outcome Measures Presentation Assignment

Description

Assessment 1 Instructions: Triple Aim Outcome Measures Presentation Assignment

• Triple Aim Outcome Measures
  • Overview: 
  • Develop a presentation, containing 10–15 slides, on the Institute for Healthcare Improvement’s Triple Aim, how current and emerging health care models support the Triple Aim, and how governmental regulatory initiatives and outcome measures can be applied in the care coordination process to achieve the Triple Aim in a population.
    The Triple Aim is a framework by the Institute for Healthcare Improvement (n.d.) for “simultaneously improving the health of the population, enhancing the experience and outcomes of the patient, and reducing per capita cost of care for the benefit of communities.” Care coordinators must have a model and framework to guide their practice and enable them to achieve the Triple Aim. Presently, many rural hospitals are using archaic models that must be updated to achieve the Triple Aim. For example, the patient-centered medical home model has been around for 30 years, but it has evolved during that time.
    By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
  • Competency 1: Apply care coordination models to improve the patient experience, promote population health, and reduce costs. 
    • Explain how the Triple Aim contributes to population health, improves the patient care experience, and reduces health care costs on a regional, state, and national level.
    • Analyze the relationships between various current and emerging health care models and the ways in which they support the Triple Aim.
    • Explain how the structure of particular health care models contributes to the process of gathering and evaluating the quality of evidence-based data.
    • Describe governmental regulatory initiatives and outcome measures that can be applied in the care coordination process to achieve the Triple Aim within a population.
  • Competency 2: Explain the relationship between care coordination and evidence-based data. 
    • Explain how evidence-based data shapes the care coordination process in nursing.
  • Competency 4: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards. 
    • Present process improvement recommendations to a stakeholder group clearly and concisely.
    • Support main points, arguments, and conclusions with relevant and credible evidence, correctly formatting citations and references using current APA style.
  • Reference
    Institute for Healthcare Improvement. (n.d.). Triple Aim for populations. Retrieved from http://www.ihi.org/Topics/TripleAim/Pages/default.aspx
    Competency Map
• Models of Care
  National initiatives focus on health care organizations to continuously improve the quality, safety, and coordination of care. In response to these initiatives, health care models have surfaced with the goal to guide national health safety and quality improvement efforts.
• Nursing is an art and science with a foundation that embraces evidence, research, and quality. The thought “we have always done it this way” has long been discarded and replaced by standards based on evidence-based research. As the specialization of care coordination has evolved, care coordination has proven to be a vital element that links patients and families to safer and higher quality care. One care coordination model, the patient-centered medical home (PCMH), has gained momentum and support from governmental and regulatory agencies.
• • Institute for Healthcare Improvement. (n.d.). Retrieved from http://www.ihi.org/Pages/default.aspx
  • Effective Presentations
    The following resources will help you create and deliver more effective presentations.
  • SoNHS Professional Presentation Guidelines [PPTX].
  • PowerPoint Presentations. 
    • This Capella library guide has links to resources on PowerPoint and other presentation software.
  • Conquering Death by PowerPoint: The Seven Rules of Proper Visual Design. 
    • This multi-part video is a primer on presentation design.
  • Writing Resources
    You are encouraged to explore the following writing resources. You can use them to improve your writing skills and as source materials for seeking answers to specific questions.
  • APA Module.
  • Academic Honesty & APA Style and Formatting.
  • APA Style Paper Tutorial [DOCX].
  • Capella Resources
  • ePortfolio. 
    • This resource provides information about ePortfolio, including how to use the different features of the product.
  • Online ePortfolio Guidelines [PDF].
  • Research Resources
    You may use other resources of your choice to prepare for this assessment; however, you will need to ensure that they are appropriate, credible, and valid. The MSN-FP6612: Emerging Health Care Models and Care Coordination Library Guide can help direct your research. The Supplemental Resources and Research Resources, both linked from the navigation menu in your courseroom, provide additional resources to help support you.
    As you review these resources, you may want to consider the following questions:
  • What is the Triple Aim, and what does it seek to accomplish?
  • How have health care models laid the foundation for care management structures?
  • How do various models influence organizational health care and system performance?
  • Imagine that you are a care coordinator at an urban teaching hospital. The patients that are served at your health care organization are ethnically, culturally, and linguistically diverse. Based on these facts, what care coordination model is best suited to guide your practice as a nurse?
  • What is the purpose and philosophy of the patient-centered medical home (PCMH) model? 
    • How does its structure contribute to the process of gathering evidence-based data?
    • How is health care quality enhanced through the PCMH model?
• Asssessment InstructionsPreparation
  In this assessment, you will assume the role of a new case manager at a small rural hospital, Sacred Heart. You have been asked to deliver an evidence-based presentation to hospital leaders and clinical leadership teams about the ways in which the care coordination process at Sacred Heart can be modified to achieve the Triple Aim within the hospital’s rural population. 
  To gain a better understanding of current health care models and their support for the Triple Aim, examine and compare such models as:
  • Patient-centered medical home (PCMH).
  • Transitional care.
  • Patient self-management.
  • Guided care.
  • Care coordination (Institute for Healthcare Improvement).
  • Then, finish gathering the information needed to prepare for your presentation by completing the following simulation exercise:
  • Vila Health: Triple Aim Outcomes.
  • Note:Remember that you can submit all or a portion of your presentation to Smarthinking for feedback before you submit the final version of this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.
    Presentation Software
    You may use Microsoft PowerPoint or any other suitable presentation software to create your slides. If you elect to use an application other than PowerPoint, check with faculty to avoid potential file compatibility issues.
    You are encouraged to review the various presentation resources provided for this assessment. These resources will help you to design an effective presentation, whether you choose to use PowerPoint or other presentation design software.
    Requirements
    Develop a presentation of specific suggestions for improving the care coordination process at Sacred Heart Hospital to achieve Triple Aim outcomes.
    Developing the Presentation
    The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your presentation addresses each point, at a minimum. You may also want to read the Triple Aim Outcome Measures Scoring Guide to better understand how each criterion will be assessed.
  • Explain how the Triple Aim contributes to population health, improves the patient care experience, and reduces health care costs on a regional, state, and national level. You will do this on slides with these specific headings:
    • Experience of Care/Patient Satisfaction.
    • Improving Population or Community Health.
    • Decreasing Per Capita Costs.
  • Analyze the relationships between various current and emerging health care models you have chosen to examine and the ways in which they support the Triple Aim by answering these guiding questions:
    • How do I define the rationale and philosophy of these health care models?
    • Can I explain how these health care models have evolved? How do I believe that these health care models have changed over time?
    • Can I cite at least three ways in which health care quality is enhanced through these models? In which three ways do I believe that these models most enhance health care quality? (Cite references to support your assertion.)
  • Explain how the structure of these models contribute to the process of gathering and evaluating the quality of evidence-based data.
  • Explain how evidence-based data shapes the care coordination process in nursing.
  • Describe three governmental regulatory initiatives and outcome measures that can be applied in the care coordination process to achieve the Triple Aim within a population.
  • Present process improvement recommendations to a stakeholder group clearly and concisely.
    • Address the anticipated needs and concerns of your audience.
    • What questions or objections are they likely to raise? How will you respond?
  • Support your main points, arguments, and conclusions with relevant and credible evidence, correctly formatting citations and references using current APA style.
    • Is your supporting evidence clear and explicit?
    • How or why does particular evidence support a claim?
    • Will your audience see the connection?
  • Additional Requirements
    PRESENTATION FORMAT AND LENGTH
    Your slide deck should consist of 10–15 slides that address the presentation criteria,not includingthe title slide, purpose slide, and references slide.
  • Begin your presentation with the following slides:
    • Title.
    • Purpose (the reasons for the presentation).
    • Definition of the Triple Aim outcome measures.
  • Use the speaker’s notes section of each slide to develop your talking points and cite your sources, as appropriate.
  • SUPPORTING EVIDENCE
  • Cite 3–5 sources of credible scholarly or professional evidence to support your presentation.
  • List your sources on the references slide at the end of your presentation.
  • Apply APA formatting to all in-text citations and references.
  • Portfolio Prompt: You may choose to save your presentation to your ePortfolio.

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NURS FPX 6610 Transitional Care Plan Paper Example

NURS FPX 6610 Assessment 3 Transitional Care Plan

NURS FPX 6610 Assessment 3 Transitional Care Plan Paper Assignment Brief

Course: NURS-FPX6610 Introduction to Care Coordination

Assignment Title: NURS FPX 6610 Assessment 3 Transitional Care Plan

Assignment Overview

This assignment requires the development of a transitional care plan for a terminally ill patient, building on decisions made in an interactive simulation regarding end-of-life care. The plan should address key elements necessary for ensuring safe transitions and improving patient outcomes during shifts between healthcare settings.

Understanding Assignment Objectives

This assignment aims to assess students’ abilities to comprehend the significance of effective care coordination, recognize barriers to information transfer in healthcare settings, and develop strategies for ensuring accurate continuity of care. Additionally, it evaluates students’ communication skills and their ability to support their assertions with credible evidence.

The Student’s Role

Students are required to assume the role of a care coordinator responsible for recommending appropriate transitional care for a terminally ill patient. They must develop a comprehensive transitional care plan that addresses the patient’s specific needs and ensures seamless transitions between healthcare settings.

You Can Also Check Other Related Assessments for the NURS-FPX6610 Introduction to Care Coordination Course:

NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment Example

NURS FPX 6610 Assessment 2 Patient Care Plan Example

NURS FPX 6610 Assessment 4 Case Presentation Example

NURS FPX 6610 Transitional Care Plan Paper Example

Transitional care is a critical aspect of patient management, especially for individuals with chronic illnesses. It ensures continuity and quality of care as patients move between different phases of treatment or healthcare settings. Its primary aim is to provide comprehensive support and resources to patients, allowing for continuous monitoring and intervention to prevent adverse outcomes. In this assessment, the focus is on developing a transitional care plan for Mrs. Snyder, a 56-year-old patient with diabetes who presented at Villa Hospital with an infected toe. The goal is to outline a plan that addresses her specific needs while considering potential barriers and communication challenges in the healthcare system (Korytkowski et al., 2022).

Key Elements and Information Needed for High-Quality Treatment

Patient quality of care and safety hinge on the adherence to strict guidelines to ensure effectiveness. Precision and effectiveness in diagnosing the patient’s condition are crucial to prevent complications (Watts et al., 2020). Moreover, continuous tracking and storage of patient medical records by the organization are essential for future reference. Proper diagnosis of Mrs. Snyder’s condition is imperative to understand her issues accurately.

Various key elements and information are necessary from Mrs. Snyder to enhance the quality of her treatment.

Medical Records: Collecting Mrs. Snyder’s medical records is paramount to address her concerns effectively. These records enable healthcare staff to identify other health issues impacting her well-being, such as depression, high blood pressure, and heart problems (Chen et al., 2018).

Medication Reconciliation: In addition to medical records, healthcare staff must be aware of Mrs. Snyder’s medication list. This reconciliation ensures whether her current medications are beneficial or if alternative options are necessary to improve her treatment outcomes (Fernandes et al., 2020).

Emergency and Advance Directive Information: A patient-centered approach is essential in transitional care planning, necessitating an understanding of Mrs. Snyder’s religious beliefs. Obtaining advance directive information from primary healthcare providers helps in understanding the patient’s previous treatment, minimizing potential complications (Dowling et al., 2020).

Patient Feedback: Furthermore, gathering patient feedback on medical personnel behavior and the treatment process is crucial. This feedback provides insights into Mrs. Snyder’s medical needs and preferences, enabling healthcare professionals to tailor their approach accordingly and empower the patient to prioritize her healthcare needs (Moghaddam et al., 2019).

Plan of Care and Education: Healthcare professionals must be adequately trained to deliver optimal care and ensure patient satisfaction. Tailoring a transitional care plan according to the patient’s specific requirements and conditions is essential. Additionally, providing access to community-based healthcare services and facilitating rapid information sharing among healthcare professionals are essential components (Dyer, 2021).

Community and Health Care Resources: Preventing adverse medical outcomes like hospital readmissions and mortality rates necessitates access to sufficient community services, including mobility options, social support, health education, and outpatient treatment (Yue et al., 2019).

Insightful Assessment of the Patient’s Needs

Transitioning Mrs. Snyder to another healthcare setting necessitates a thorough understanding of her medical background, current health status, and treatment trajectory. Essential components of this assessment include acquiring medical test results, documenting her post-discharge prescriptions, and evaluating the duration of her hospitalization (Humphries et al., 2020). Furthermore, crucial documents such as counseling records, follow-up plans, and information about available social support services must be obtained to ensure comprehensive care coordination. Additionally, assessing Mrs. Snyder’s current health status and conducting enhanced safety assessments are vital aspects of this process. Moreover, a detailed review of her treatment history, particularly regarding chronic illnesses, is imperative for maintaining continuity of care and optimizing health outcomes. By addressing these multifaceted needs, we can effectively facilitate Mrs. Snyder’s transition while promoting her overall well-being.

Importance of Key Elements of a Transitional Care Plan

In transitional care plans, each key element holds crucial significance in enhancing the quality of patient care. Gathering emergency and advance directive information from previous healthcare settings is vital for healthcare professionals to anticipate potential issues and address them effectively. Understanding Mrs. Snyder’s religious and cultural beliefs, as suggested by Blackwood et al. (2019), ensures that her care aligns with her preferences and avoids conflicts. Advance directives, according to Blackwood et al. (2019), aid in making future health decisions, emphasizing the importance of advanced care planning in assessing patients’ needs and preferences.

For Mrs. Snyder, access to community and healthcare resources is imperative to address her specific needs. Suffering from an infected toe, accommodations such as ground-floor rooms or elevator facilities can alleviate her mobility challenges, as highlighted by Schultz et al. (2021). Additionally, ensuring the availability of wheelchairs within the hospital premises is essential to prevent complications. Schultz et al. (2021) emphasize the role of healthcare services and community support in reducing hospital readmission rates and providing essential medical care post-discharge.

Medication reconciliation stands as a critical aspect of transitional care, aiding in identifying allergies and preventing medication errors. Borulkar et al. (2022) stress the importance of medication reconciliation in patient care and safety, particularly for patients like Mrs. Snyder who require insulin therapy. Accurate dosing of insulin is crucial to avoid severe consequences, emphasizing the significance of this process in patient management.

Patient feedback serves as a valuable tool for healthcare staff to assess concerns and address potential gaps in care. Fiorillo et al. (2020) highlight the necessity of patient feedback in treatment decision-making, citing its role in mitigating instances of negligence and improving overall patient experience. Learning from Mrs. Snyder’s experience with post-discharge guidelines underscores the importance of incorporating patient feedback into care protocols to prevent similar occurrences in the future.

Furthermore, enhancing healthcare professionals’ and patients’ training can significantly improve Mrs. Snyder’s quality of care. Training programs equip healthcare professionals with the skills for effective collaboration and communication, facilitating better understanding of patients’ needs and preferences. Kaper et al. (2019) emphasize the necessity of training to reduce mortality rates and enhance patient care quality, highlighting its role in addressing individual patient requirements and improving overall outcomes. By prioritizing these key elements, healthcare providers can tailor transitional care plans to meet Mrs. Snyder’s specific needs, ultimately enhancing her well-being and quality of life.

Potential Effects of Incomplete or Inaccurate Information on Care

Ensuring the transfer of complete and accurate patient information between healthcare settings is crucial to avoid treatment delays and serious complications. Inaccurate or incomplete data can lead to erroneous treatment decisions, increased mortality rates, and higher readmission rates. Medication errors are also a significant concern, as incomplete prescription lists may result in administering incorrect medications, posing risks to patient safety. Zirpe et al. (2020) highlight the impact of incomplete drug information on treatment delays and mortality rates, emphasizing the importance of accurate prescription records in healthcare organizations.

Importance of Effective Communication

Effective communication among healthcare providers is essential for obtaining comprehensive patient medical histories. It fosters a positive rapport between patients and healthcare professionals, enhancing patient trust and adherence to care plans. Garcia-Jorda et al. (2022) emphasize the role of effective communication in building trust and ensuring patient commitment to treatment plans. Furthermore, clear communication facilitates informed decision-making regarding patient well-being, allowing healthcare staff to obtain accurate updates on patients’ conditions from previous healthcare providers. In the case of Mrs. Snyder, who is experiencing stress and depression due to treatment costs, effective collaboration and emotional support are vital for addressing her mental health needs. Yazdinejad et al. (2020) underscore the importance of effective communication in reducing adverse events and mortality rates, highlighting its role in ensuring patient safety and optimal care delivery within healthcare organizations.

Potential Effects of Ineffective Communication

When communication among healthcare providers is ineffective, it can lead to significant consequences such as delays in delivering prompt and appropriate treatment. In emergency situations, inadequate communication may result in delays in administering urgent care, as healthcare staff may lack accurate patient information. This delay can exacerbate health conditions and potentially lead to adverse outcomes, including mortality (Raeisi et al., 2019). Furthermore, ineffective communication can contribute to disparities in healthcare delivery, further jeopardizing patient well-being and potentially resulting in fatal consequences.

Moreover, ineffective communication can contribute to increased healthcare costs for patients. Without proper communication between healthcare settings, patients may undergo unnecessary duplicate tests or procedures, leading to additional expenses. This lack of coordination can strain patients financially and burden the healthcare system unnecessarily. Additionally, inadequate communication can erode trust and satisfaction in healthcare professionals among patients. When patients feel their needs are not adequately addressed due to communication gaps, it diminishes their confidence in the healthcare system and may negatively impact their overall care experience (Raeisi et al., 2019).

Barriers to the Transfer of Accurate Patient Information

The seamless transfer of accurate patient information is vital for the success of any transitional care plan. However, several barriers may impede this process. One significant obstacle is the shortage of staff, which can hinder the effective sharing of information. In busy transitional periods, nurses and other healthcare personnel may find themselves overwhelmed with duties, leading to potential miscommunication (Ilardo & Speciale, 2020).

Incomplete medical histories pose another challenge, as missing test results and diagnosis documents can lead to communication gaps. This incompleteness may result in the duplication of tests and procedures, causing delays and inefficiencies in patient care.

Moreover, the financial burden on patients and their families due to the repetition of tests can arise if insurance coverage does not extend to such circumstances. Adequate planning and information exchange are crucial to address this concern and ensure efficient resource utilization (Cullati et al., 2019).

Additionally, a lack of familiarity with Electronic Health Records (EHR) technology among healthcare professionals presents another barrier to effective communication. Without proper training in EHR systems, healthcare providers may struggle to transfer patient information accurately, potentially compromising patient safety and continuity of care (Tsai et al., 2020).

Strategy for Ensuring Comprehensive Continuity of Care

Implementing effective strategies is crucial to delivering optimal care to patients during transitions. One key strategy involves meticulous planning to ensure the accurate transfer of patient information to destination healthcare facilities. This approach aims to mitigate financial burdens on patients and minimize the risk of adverse outcomes, such as mortality. By meticulously documenting Mrs. Snyder’s complete medical history, including medication reconciliation, destination hospitals can prevent potential complications associated with incorrect medication administration (Glans et al., 2020).

Conducting follow-up sessions is another valuable strategy to gain insight into Mrs. Snyder’s perspective on the destination medical center. Adopting a collaborative approach fosters open communication and enables healthcare providers to address patient concerns effectively. Moreover, providing comprehensive discharge instructions, including allergy information and self-management plans, is essential for ensuring Mrs. Snyder’s adherence to a healthy lifestyle post-transition. Prioritizing these strategies is integral to the success of the transitional care plan and promoting positive patient outcomes (Spencer & Singh Punia, 2020).

Conclusion

Effective transitional care planning is essential for patients, particularly those with chronic illnesses like Mrs. Snyder. By addressing key elements such as comprehensive medical records, medication reconciliation, patient feedback, and effective communication, healthcare providers can enhance the quality of care and improve patient outcomes during transitions between healthcare settings. Furthermore, recognizing and overcoming barriers to information transfer, such as staffing shortages and incomplete medical histories, is crucial for ensuring seamless continuity of care. Implementing strategies like meticulous planning, follow-up sessions, and comprehensive discharge instructions can further enhance the effectiveness of transitional care plans. By prioritizing these aspects, healthcare providers can optimize patient well-being and promote successful transitions across the healthcare continuum.

References

Borulkar, V., Weingart, S. N., Rutherford, P. A., & Taylor, L. E. (2022). Medication reconciliation: a necessary yet insufficient tool to prevent medication errors. Journal of Patient Safety, 18(1), e154-e156.

Chen, Y., Zhang, J., Lyu, H., Liu, X., Cao, Z., Gao, R., … & Lu, X. (2018). The value of medication reconciliation in a patient-centered medical home. Journal of Patient Safety, 14(4), e74-e79.

Cullati, S., Charvet-Bérard, A. I., Perneger, T. V., & Charvet-Bérard, A. (2019). Transfer of information and healthcare system utilization after patient discharge from intensive care. Journal of Patient Safety, 15(2), e82-e88.

Dowling, M., Hunter, A., & Plumb, M. (2020). The importance of advance care planning in the hospital. British Journal of Nursing, 29(6), 346-349.

Dyer, S. M. (2021). Transitional care interventions for preventing hospital readmissions for older people with heart failure: A systematic review and meta-analysis. Heart & Lung, 50(3), 315-325.

Fernandes, S. S., Silva, A. E., Pereira, A. R., & Lopes, I. C. (2020). Medication reconciliation in clinical practice: a systematic review. International Journal of Clinical Pharmacy, 42(5), 1218-1230.

Fiorillo, L., Cornelli, P., & Montorselli, C. (2020). Patient satisfaction: A key factor in clinical evaluation. European Review for Medical and Pharmacological Sciences, 24(3), 1397-1400.

Glans, M., Lindström, K., & Olofsson, T. C. (2020). Improving discharge planning in an acute care hospital: Assessment of a comprehensive discharge planning tool. Journal of Clinical Nursing, 29(19-20), 3695-3704.

Garcia-Jorda, D., Rodriguez-Vicente, I., Gomez-Martinez, M. J., Fuentes-Pumarola, C., Llaurado-Serra, M., & Vinas-Sanchez, S. (2022). Effective communication in nursing: A qualitative study. Nurse Education Today, 109, 105263.

Humphries, A., Tann, L. S., Osborne, M., & Law, T. (2020). Adherence to care plan documents: a key for safe transitions. Australian Journal of Primary Health, 26(2), 118-122.

Ilardo, M. L., & Speciale, R. P. (2020). Nursing shortages and patient safety outcomes: a systematic review of the literature. Journal of Nursing Management, 28(5), 1060-1069.

Kaper, M. S., Sixma, H. J., & van der Meer, J. T. (2019). Are patients discharged with care? A qualitative study of perceptions and experiences of patients, family members and care providers. BMJ Quality & Safety, 28(5), 328-336.

Moghaddam, A., Farhangi, H., Pourreza, A., & Nikbakht Nasrabadi, A. (2019). Development of nursing services: A qualitative study. Journal of Nursing Management, 27(5), 975-984.

Raeisi, A. R., Farhangi, H., Moosavi, S., & Khaleghi, M. (2019). The effect of communication skills training on quality of nursing care. Evidence Based Care, 9(1), 17-25.

Schultz, M. S., Oliver, R. D., Kofoed, J. F., & Carroll, J. S. (2021). Community-based health care: implications for nurse executives. Nursing Administration Quarterly, 45(2), 160-170.

Spencer, C., & Singh Punia, M. (2020). The importance of patient education in nursing care. British Journal of Nursing, 29(11), 652-655.

Tsai, C. W., Kung, P. T., Wang, C. W., Chang, Y. C., & Huang, H. L. (2020). The barriers to the adoption of electronic medical records by physicians: a systematic review of the literature. Journal of Medical Systems, 44(1), 4.

Watts, G., Lee, K., Hanning, B., & Williams, J. (2020). Nursing shortage and nurse turnover. Nursing Economics, 38(3), 129-139.

Yazdinejad, A., Gheibizadeh, M., Jahangiri, M., Jafarabadi, M. A., & Ghafari, S. (2020). Investigating the effectiveness of communication skills training on communication skills of medical students. Journal of Medical Education Development, 14(4), 358-364.

Yue, D. S., Zhang, Y. Y., Zhang, Y., & Liu, G. (2019). The impact of discharge planning on the readmission of elderly patients after hip fracture: A systematic review and meta-analysis of randomised controlled trials. BMC Musculoskeletal Disorders, 20(1), 1-11.

Zirpe, K. G., Gurjar, M., Kumar, R., Baronia, A. K., & Kishore, K. (2020). Impact of medication reconciliation on medication errors in critically ill patients. Critical Care and Resuscitation, 22(2), 104-109.

Detailed Assessment Instructions for the NURS FPX 6610 Assessment 3 Transitional Care Plan Paper Assignment

Description

Assessment 3 Instructions: Transitional Care Plan Paper Assignment

• Complete an interactive simulation in which you will make decisions about a patient’s end-of-life care. Then, develop a transitional care plan of 4–5 pages for the patient.
  Note: Each assessment in this course builds on your work from the preceding assessment; therefore, complete the assessments in the order in which they are presented.
  To help reduce care fragmentation, a care coordinator working with patients who suffer from chronic illnesses must share important clinical information with stakeholders so everyone has clear shared expectations about their roles. Equally important, the care coordinator must work with the team to provide updated information to patients and their families and to ensure that effective transitions and referrals take place. This assessment provides an opportunity for you to assume the role of care coordinator and recommend appropriate transitional care for a terminally ill patient.
  Relative to other facets of medical care, research directing efforts to improve care coordination has lacked rigor. However, many groundbreaking health care organizations have acknowledged the perils of poorly coordinated care models and applied interventions to improve these models. The objective of care coordination is to secure high-quality recommendations and transitions that aim for superior health care and guarantee that all involved providers, organizations, and patients have the necessary information and resources to make optimal patient care possible.
  By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
  • Competency 2: Explain the effect of societal, economic, and interprofessional factors on patient outcomes and the care coordinator’s role.
    • Explain the importance of effective communications with other health care and community services agencies.
    • Identify barriers to the transfer of accurate patient information from the sending organization to the patient destination.
  • Competency 3: Evaluate care coordination plans and outcomes according to performance measures and professional standards.
    • Explain the importance of each key element of a transitional care plan.
  • Competency 4: Develop collaborative interventions that address the needs of diverse populations and varied settings.
    • Provide the key plan elements and information needed to ensure safe, high-quality transitional care and improved patient outcomes.
    • Develop a strategy for ensuring that the destination care provider has an accurate understanding of continued care.
  • Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
    • Write clearly and concisely, using correct grammar and mechanics.    
    • Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.
  • Competency Map
    CHECK YOUR PROGRESSUse this online tool to track your performance and progress through your course.
• Toggle DrawerResources
• Asssessment InstructionsNote: Complete the assessments in this course in the order in which they are presented.
  Preparation
  In the previous assessment, you conducted simulated stakeholder interviews and collected information for a plan of care for Mrs. Snyder. Now, seven months later, her condition has deteriorated.
  To prepare for this assessment, complete the following simulation:
  • Vila Health: Care Coordination Scenario II.
  • In this simulation, you will recommend appropriate end-of-life care for Mrs. Snyder and see how those recommendations can affect the lives of the patient and her family. Completing this exercise will help you develop a transitional care plan for Mrs. Snyder.
    Note: Remember that you can submit all or a portion of your draft to Smarthinking for feedback before you submit the final version of this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.
    Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:
  • Assessment 3 Example [PDF].
  • Requirements
    Develop a transitional care plan for Mrs. Snyder.
    Transitional Care Plan Format and Length
    You may use a familiar transitional care plan format or template—for example, one used in your organization—or you may create your own. See the Transition Care Plan Example [PDF] provided.
  • Format your transitional care plan in APA style; an APA Style Paper Tutorial [DOCX] is provided to help you. Be sure to include:
    • A title page and references page. An abstract is not required.
    • A running head on all pages.
    • Appropriate section headings.
  • Your plan should be 4–5 pages in length, not including the title page and references page.
  • Supporting Evidence
    Cite 3–5 sources of scholarly or professional evidence to support your plan.
    Developing the Transitional Care Plan
    The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your transitional care plan addresses each point, at a minimum. Read the Transitional Care Plan Scoring Guide to better understand how each criterion will be assessed.
  • Provide the key plan elements and information needed to ensure safe, high-quality transitional care and improved patient outcomes.
    • Include elements such as emergency and advance directive information, medication reconciliation, plan of care, and available community and health care resources.
  • Explain the importance of each key element of a transitional care plan.
    • Identify potential effects of incomplete or inaccurate information on patient outcomes and the quality of care.
    • Cite credible evidence to support your assessment of each element’s importance.
  • Explain the importance of effective communications with other health care and community services agencies.
    • Identify potential effects of ineffective communications on patient outcomes and the quality of care during the transition.
  • Identify barriers to the transfer of accurate patient information from the sending organization to the patient destination.
    • Consider barriers (actual or potential) inherent in such care settings as long-term care, subacute care, home care services, and home care with support, family involvement, et cetera.
    • Identify at least three barriers (actual or potential).
  • Develop a strategy for ensuring that the destination care provider has an accurate understanding of continued care.
    • Consider the patient medication list, plan of care, or other aspects of the follow-up plan or discharge instructions.
    • Cite credible evidence to support your strategy.
  • Write clearly and concisely, using correct grammar and mechanics.
    • Express your main points and conclusions coherently.
    • Proofread your writing to minimize errors that could distract readers and make it difficult to focus on the substance of your plan.
  • Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.
  • Portfolio Prompt: You may choose to save your transitional care plan to your ePortfolio.

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NURS FPX 6610 Comprehensive Needs Assessment Paper Example

NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment

NURS FPX 6610 Comprehensive Needs Assessment Paper Assignment Brief

Course: NURS-FPX6610 Introduction to Care Coordination

Assignment Title: NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment

Overview Assignment

The Comprehensive Needs Assessment Paper Assignment in NURS FPX 6610 involves conducting a thorough assessment of a patient’s care requirements based on an interactive simulation. This assignment aims to evaluate the student’s ability to identify gaps in patient care, develop strategies for gathering additional assessment data, and advocate for evidence-based practices and multidisciplinary approaches to patient care coordination.

Understanding Assignment Objectives

The primary objective of this assignment is to assess the student’s competency in developing patient assessments, understanding the impact of societal, economic, and interprofessional factors on patient outcomes, evaluating care coordination plans according to professional standards, identifying evidence-based practices for care coordination, and communicating effectively using appropriate academic language and APA formatting.

The Student’s Role

As a student, your role is to analyze the case of Mr. Decker, a patient with complex health issues, and conduct a comprehensive needs assessment based on the information provided in the Vila Health simulation and additional research. You will identify gaps in Mr. Decker’s care, develop a strategy for gathering additional assessment data, discuss societal and economic factors affecting patient outcomes, relate patient and care coordination measures to professional standards, identify evidence-based practices for care coordination, and advocate for the benefits of a multidisciplinary approach to patient care.

Competencies Measured

This assignment measures several key competencies essential for nursing practice:

• Develop patient assessments: Identify current gaps in a patient’s care and develop strategies for gathering additional assessment data.
• Explain the effect of societal, economic, and interprofessional factors on patient outcomes: Discuss factors likely to affect patient outcomes and advocate for a multidisciplinary approach to patient care.
• Evaluate care coordination plans and outcomes: Relate patient and care coordination outcome measures to professional standards.
• Develop collaborative interventions: Identify evidence-based practices for successful implementation of care coordination.
• Communicate effectively: Write clearly and concisely, supporting main points with credible evidence and correctly formatting citations and references using APA style.

You Can Also Check Other Related Assessments for the NURS-FPX6610 Introduction to Care Coordination Course:

NURS FPX 6610 Assessment 2 Patient Care Plan Example

NURS FPX 6610 Assessment 3 Transitional Care Plan Example

NURS FPX 6610 Assessment 4 Case Presentation Example

NURS FPX 6610 Comprehensive Needs Assessment Paper Example

Introduction

Comprehensive needs assessment serves as a cornerstone in optimizing patient care by identifying gaps and formulating strategies to address them. This assessment focuses on Mr. Decker, a 79-year-old diabetic patient, to evaluate his care requirements and implement effective care coordination strategies. Through interdisciplinary collaboration and adherence to professional standards, the aim is to improve patient outcomes and ensure the delivery of high-quality care. This process is essential for healthcare professionals to understand patient needs thoroughly and develop appropriate interventions to enhance overall patient care.

Current Gaps in Patient Care

Mr. Decker, a 79-year-old diabetic patient, was admitted to the hospital due to an infected toe. Unfortunately, his failure to follow post-discharge instructions resulted in his readmission with a severe infection. Several gaps in his care became evident during this process. Firstly, Mr. Decker comes from a low-income family, which makes it challenging for him to afford expensive treatments. However, this aspect was overlooked by the healthcare provider. Secondly, there was a lack of comprehensive education provided regarding Mr. Decker’s post-discharge healthcare routine, contributing to the deterioration of his health. Additionally, there is a gap in the healthcare system’s practice of evaluating patient conditions after discharge, which could have prevented Mr. Decker’s readmission.

The Patient-Centered Assessment Method was utilized as a needs evaluation tool to ensure that Mr. Decker’s physiological, social, religious, and psychological needs were addressed (Perazzo et al., 2020). This tool was selected because it prioritizes an approach focused on effort, aiming to provide extensive care by considering the patient’s emotional well-being.

Informational Needs for Optimal Patient Care

Ensuring Mr. Decker receives the best possible care requires specific information about him. Accessing his medical records, including details such as age, weight, and any allergic conditions, is crucial for assessing his current health status and informing treatment decisions. Furthermore, understanding Mr. Decker’s emotional state, desires, medical schedule, and religious beliefs is essential for evaluating whether his needs are being met effectively. Additionally, gathering insights from his family members can provide valuable information to tailor his care plan effectively.

Strategy for Gathering Additional Necessary Data

In order to obtain a comprehensive understanding of Mr. Decker’s condition, healthcare professionals must engage in preliminary discussions and seek additional information from his family (Mertens et al., 2020). Interviewing family members, such as his spouse and children, who are familiar with him, can provide valuable insights into his behavior, interests, diet, and other factors crucial for his optimal care. Exploring the possibility of using social media to gather relevant information is advisable, despite Mr. Decker’s older age. Additionally, interviewing his friends can offer further insights into his hobbies and routines.

Utilizing electronic health records is another valuable tool for obtaining prior health history and treatment details from previous healthcare providers. However, it is imperative to adhere to HIPAA regulations and obtain the patient’s consent before accessing their data (Shah & Khan, 2020). Patient registration documents and routine follow-up records can also be utilized to gather data consistently.

Furthermore, systems for exchanging health records among healthcare professionals facilitate obtaining Mr. Decker’s longitudinal medical data from various sources. This comprehensive approach enables healthcare professionals to gain insights into the diverse effects of Mr. Decker’s conditions, such as diabetes and aging, on his health. By employing these strategies, healthcare providers adopt a holistic and coordinated care perspective, enhancing their ability to gather in-depth knowledge about Mr. Decker’s medical history and ultimately improving patient care (Mertens et al., 2020).

Societal, Economic, and Interdisciplinary Factors Impacting Patient Care

The dynamics of patient care are influenced by a multitude of factors encompassing societal, economic, and interdisciplinary dimensions. Among these factors, aging emerges as a pivotal concern, particularly for individuals like Mr. Decker, a 79-year-old patient. With advancing age, patients often encounter a myriad of health issues, including weight loss, weakened bones, reduced appetite, and sensory impairments, complicating diagnostic procedures and treatment plans (Liu et al., 2019).

Economic determinants significantly impact Mr. Decker’s health outcomes, with his income status serving as a key factor. Originating from a low-income family, Mr. Decker relies on medical insurance for accessing treatment (Palileo-Villanueva et al., 2022). While insurance may cover hospitalization expenses, ancillary costs such as therapy services are typically not included, posing financial barriers to accessing recommended treatments and impacting the overall quality of care (Palileo-Villanueva et al., 2022).

Moreover, the absence of social support exacerbates Mr. Decker’s situation, as his family members are unable to provide regular emotional reinforcement or assist with post-discharge procedures (Ko et al., 2019). Research underscores the significance of social support for the health outcomes of elderly patients, highlighting the heightened susceptibility of individuals lacking such support to experience complications (Milgrom et al., 2019). The dearth of emotional reinforcement and caregiving exacerbates Mr. Decker’s vulnerability, potentially leading to adverse health outcomes.

Influences of Professional Standards on Patient Care and Coordination Outcomes

Adherence to professional standards, as established by organizations such as the National Quality Forum and the Agency for Healthcare Research and Quality, is fundamental in delivering safe and high-quality care. These standards are designed to enhance patient safety and care coordination outcomes by providing valuable frameworks and evaluation criteria.

The National Quality Forum, founded in 2017, is dedicated to setting standards for safety and care coordination, aiming to elevate the quality of care provided to patients (Namburi & Lee, 2022). One of its frameworks, the Care Coordination and Transition Management Logic Model, serves as a valuable tool for assessing the effectiveness of care coordination efforts (Hofmann & Erben, 2020). This model emphasizes the importance of aligning nurses’ competencies with care coordination activities to achieve patient-centered outcomes.

Additionally, the Agency for Healthcare Research and Quality has developed care coordination evaluation standards focused on enhancing care coordination through various methods, including communication, collaboration, and routine check-ups (Artiga et al., 2020). These standards prioritize patient feedback and stakeholder input, reflecting a patient-centered approach to care coordination.

By implementing evidence-based practices and utilizing these care coordination models, healthcare professionals can ensure optimal patient outcomes while adhering to professional standards.

Evidence-Based Approaches for Effective Patient Care Coordination Implementation

In caring for elderly patients with infections, evidence-based strategies like GENESIS (Generalized Early Sepsis Intervention Strategies), and routine evaluation protocols provide reliable methods for managing illnesses and preventing complications. GENESIS, which focuses on promptly identifying infection outbreaks and assessing sepsis-related mortality rates, has demonstrated a significant reduction in mortality rates (Kregel et al., 2022). Routine evaluation protocols, particularly for older patients with conditions such as diabetes or high blood pressure, involve continuous monitoring of vital signs and regular assessments to detect sepsis early (LeRoith et al., 2019).

Another effective strategy is the implementation of multidisciplinary interventions like the sepsis six bundles, which aim to reduce mortality rates following a sepsis diagnosis (Bleakley & Cole, 2020). These bundles include actions such as monitoring urine output, maintaining oxygen saturation, administering antibiotics, and monitoring glucose levels. By leveraging evidence-based practices and multidisciplinary interventions, healthcare providers can enhance the effectiveness of care delivery and minimize adverse outcomes.

Benefits of a Multidisciplinary Approach to Patient Care

A multidisciplinary approach promotes comprehensive patient care by harnessing the expertise of various healthcare professionals to address diverse patient needs. By integrating insights from different disciplines, this approach optimizes treatment plans, reduces errors, and improves patient outcomes. In the case of Mr. Decker, for example, a multidisciplinary team comprising professionals skilled in elderly care, psychology, and social work could have tailored a more holistic treatment plan considering his age and diabetes. Delegating tasks among team members streamlines processes and minimizes errors, thereby enhancing the quality of care. Failure to consider age and socioeconomic factors can lead to medication errors, underscoring the importance of early adoption of a multidisciplinary approach to prevent health deterioration. Moreover, a multidisciplinary strategy helps bridge gaps in patient care resulting from social, economic, and interprofessional factors, ultimately leading to reduced readmissions and improved patient outcomes (Ni et al., 2019).

Conclusion

Comprehensive needs assessment and care coordination play pivotal roles in patient care, particularly for individuals like Mr. Decker who face complex health challenges. By identifying gaps and leveraging interdisciplinary collaboration, healthcare professionals can enhance the quality of care and ensure better outcomes for their patients. Through adherence to professional standards and evidence-based practices, healthcare providers can tailor interventions to meet the unique needs of each patient effectively. The adoption of a multidisciplinary approach promotes comprehensive patient care by harnessing the expertise of various healthcare professionals, streamlining processes, and minimizing errors. By integrating these approaches into clinical practice, healthcare organizations can strive towards improving patient outcomes, minimizing readmissions, and enhancing the overall quality of care.

References

Artiga, S., Hinton, E., & Huguet, N. (2020). Beyond health care: the role of social determinants in promoting health and health equity. The Henry J. Kaiser Family Foundation.

Bleakley, C., & Cole, A. (2020). Sepsis: diagnosis and management. BMJ, 368, l6741.

Hofmann, E., & Erben, J. (2020). Interdisciplinary teamwork in hospitals: A review of the literature. Business: Theory and Practice, 21, 504-513.

Kregel, K., Lanting, P., & Domanski, J. (2022). Generalized Early Sepsis Intervention Strategies (GENESIS): Reducing Infection-related Mortality Rates by 14%. Journal of Nursing, 15(3), 280-288.

LeRoith, D., Biessels, G. J., Braithwaite, S. S., Casanueva, F. F., Draznin, B., Halter, J. B., … & Reagan, L. (2019). Treatment of diabetes in older adults: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 104(5), 1520-1574.

Milgrom, L. B., Shelton, J., Patel, K. K., Kirchhoff, K. T., Sodeke, S. O., & Pang, K. A. (2019). Social determinants of health: an essential tool to address hospital readmissions. The Ochsner Journal, 19(1), 28-32.

Namburi, J., & Lee, J. J. (2022). Care coordination as a patient safety initiative. American Journal of Medical Quality, 37(1), 44-49.

Ni, H., Nauman, E., & Burgess Jr, J. F. (2019). Hospital readmission, emergency department visits, and costs following an episode of sepsis. JAMA, 322(16), 1593-1595.

Palileo-Villanueva, L., Richards, K. C., & Jordan, S. L. (2022). The effects of socioeconomic status on health outcomes and quality of life for older adults receiving care in the community. Journal of Applied Gerontology, 41(1), 98-106.

Perazzo, J. D., Wallace, M., & Morano, M. T. (2020). The Patient-Centered Assessment Method: A Validated Tool for Health Care Professionals. The Journal of Nursing Care, 14(3), 260-267.

Shah, S., & Khan, M. U. (2020). Electronic health records: A practical approach. Journal of Multidisciplinary Healthcare, 13, 147-155.

Detailed Assessment Instructions for the NURS FPX 6610 Comprehensive Needs Assessment Paper Assignment

Description

Assessment 1 Instructions: Comprehensive Needs Assessment Paper Assignment

• Complete an interactive simulation of the role of the nurse in health care coordination. Then, create a comprehensive patient needs assessment of 4–5 pages based on that simulation.
  Note: Each assessment in this course builds on your work from preceding assessments; therefore, complete the assessments in the order in which they are presented.

SHOW LESS

• Care coordination is an emerging and complex field in the health care system because of the growing number of providers, the various settings of care, and the numerous methods of delivering care. Hospitals are implementing several interventions to address gaps in care coordination, such as enhanced systems of communication, information technology, and personnel resourcing. This assessment provides an opportunity for you to complete a comprehensive needs assessment.
  In the 2000 report To Err Is Human: Building a Safer Health System, the Institute of Medicine identified collaborative communication and the reduction of medical errors as top priorities to improve the quality and safety of patient care. In response to this, the National Quality Forum (NQF), a nonprofit organization that works to catalyze improvements in health care, identified care coordination as an important national strategy to improve patient safety and quality of care delivery.
  Coordination of care supports patient safety and quality and is a recognized professional standard shared by registered nurses regardless of their practice settings. Whether educating a patient about his or her medication and plan of care or reviewing follow-up care, nurses are essential in facilitating the continuity of care for all patients. Historically, nurses have engaged in coordinating care for every one of their patients. As the landscape of health care evolves, so does care coordination.
  By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
  • Competency 1: Develop patient assessments. 
    • Identify current gaps in a patient’s care.
    • Develop a strategy for gathering additional necessary assessment data not readily available from an initial patient interview.
  • Competency 2: Explain the effect of societal, economic, and interprofessional factors on patient outcomes and the care coordinator’s role. 
    • Discuss societal, economic, and interprofessional factors most likely to affect patient outcomes.
    • Advocate for the benefits of a multidisciplinary approach to patient care.
  • Competency 3: Evaluate care coordination plans and outcomes according to performance measures and professional standards. 
    • Relate specific patient and care coordination outcome measures to professional standards.
  • Competency 4: Develop collaborative interventions that address the needs of diverse populations and varied settings. 
    • Identify evidence-based practices for successful implementation of care coordination.
  • Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards. 
    • Write clearly and concisely, using correct grammar and mechanics.    
    • Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.
  • Reference
    Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press.
    Competency Map
    CHECK YOUR PROGRESSUse this online tool to track your performance and progress through your course.
• Toggle DrawerResources
• Asssessment InstructionsNote: Complete the assessments in this course in the order in which they are presented.
  Preparation
  To prepare for this assessment, complete the following simulation:
  • Vila Health: The Nurse’s Role in Care Coordination.
  • This simulation explores the roles that case managers and other team members play in care coordination. Upon completion of the exercise, you should have a better understanding of care coordination trends and their historical contexts. Use the information available in this simulation to begin your assessment of the patient, Mr. Decker.
    Note: Remember that you can submit all or a portion of your draft to Smarthinking for feedback before you submit the final version of this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.
    Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:
  • Assessment 1 Example [PDF].
  • Requirements
    Complete a comprehensive needs assessment for Mr. Decker, based on the information provided in the Vila Health simulation and your own research.
    Comprehensive Needs Assessment Format and Length
    Format your comprehensive needs assessment using APA style:
  • Use the APA Style Paper Template [DOCX] provided. Be sure to include: 
    • A title page and references page. An abstract is not required.
    • A running head on all pages.
    • Appropriate section headings.
  • See also the APA Style Paper Tutorial [DOCX] to help you in writing and formatting your needs assessment.
  • Your needs assessment should be 4–5 pages in length, not including the title page and references page.
  • Supporting Evidence
    Cite 3–5 sources of scholarly or professional evidence to support your assessment.
    Conducting the Assessment
    The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your needs assessment addresses each point, at a minimum. Read the Comprehensive Needs Assessment Scoring Guide to better understand how each criterion will be assessed.
  • Identify current gaps in a patient’s care. 
    • Use an appropriate needs assessment tool to identify gaps. This tool may be one in use at your place of employment, one you locate for yourself, or one provided by faculty.
    • Consider the types of patient information that will be most useful in assessing the current level of care.
  • Develop a strategy for gathering additional necessary assessment data not readily available from an initial patient interview. 
    • Consider the full range of interrelated needs that affect the patient’s health.
  • Discuss 3–5 societal, economic, and interprofessional factors most likely to affect patient outcomes. 
    • Consider the potential effects of these factors on outcomes.
    • Support your conclusions with evidence.
  • Relate specific patient and care coordination outcome measures to professional standards. 
    • Provide the rationale for measuring outcomes based on established agencies and organizations.
    • Describe the relationship between specific outcomes and the identified standards.
  • Identify evidence-based practices for successful implementation of care coordination. 
    • Use relevant and credible sources from the research literature.
    • Consider best practices for a population-health focus on patient outcomes.
  • Advocate for the benefits of a multidisciplinary approach to patient care. 
    • Provide the key points in your argument.
    • Support your assertions with evidence.
  • Write clearly and concisely, using correct grammar and mechanics. 
    • Express your main points and conclusions coherently.
    • Proofread your writing to minimize errors that could distract readers and make it more difficult to focus on the substance of your needs assessment.
  • Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.
  • Portfolio Prompt: You may choose to save your comprehensive needs assessment to your ePortfolio.

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