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NURS FPX 6616 Community Resources and Best Practices Paper Example

NURS FPX 6616 Assessment 1 Community Resources and Best PracticesNURS FPX 6616 Assessment 1 Community Resources and Best Practices

Assignment Brief: NURS FPX 6616 Community Resources and Best Practices Paper

Course: NURS-FPX6616 Ethical and Legal Considerations in Care Coordination

Assignment Title: NURS FPX 6616 Assessment 1 Community Resources and Best Practices

Assignment Overview

In this assignment, you will develop a presentation consisting of 8–10 slides for the leaders of a healthcare organization or community-based care delivery service. The purpose of the presentation is to explore current organizational or community resources for a specific situation related to care delivery. You will analyze legal and ethical considerations, propose recommendations for improvement, identify evidence-based interventions, and outline strategies for sustainability.

Understanding Assignment Objectives

As a student, your role is to conduct a thorough exploration of care delivery practices and associated legal and ethical implications. You will need to critically evaluate current practices, propose evidence-based interventions, and develop recommendations for improvement. Your goal is to enhance care delivery by addressing the complexities of ethical and legal considerations in healthcare.

Competencies Measured

This assignment assesses your ability to:

  • Analyze ethical issues pertaining to the use of health care information systems for care coordination.
  • Evaluate the legal issues associated with current practices and propose potential changes.
  • Compare current outcomes to outcomes seen with best practices.
  • Identify appropriate evidence-based interventions relevant to the specific care delivery situation.
  • Define the roles of stakeholders and interprofessional teams in implementing interventions.
  • Explain the use of data-driven outcomes, including data measures and evaluation periods.
  • Recommend ongoing practices to sustain intervention outcomes.
  • Communicate effectively in a scholarly and professional manner consistent with academic expectations.

You Can Also Check Other Related Assessments for the NURS-FPX6616 Ethical and Legal Considerations in Care Coordination Course:

NURS FPX 6616 Assessment 2 Summary Report on Rural Health Care and Affordable Solutions Example

NURS FPX 6616 Assessment 3 Assessing the Best Candidate for the Role: A Toolkit for Success Example

NURS FPX 6616 Community Resources and Best Practices Paper Example

Title Slide:

Title: Enhancing Care Delivery: Exploring Ethical and Legal Considerations

Subtitle: Leveraging Community Resources and Best Practices

Presenter: [Your Name]

Date: [Presentation Date]

Slide 2: Purpose

  • Greetings esteemed leaders of [Healthcare Organization/Community-Based Care Delivery Service].
  • Today’s presentation focuses on enhancing care delivery through the exploration of ethical and legal considerations.
  • We aim to underscore the significance of understanding ethical and legal implications in healthcare delivery.
  • Emphasize the pivotal role of evidence-based interventions and interprofessional collaboration.
  • Augment patient outcomes and foster quality care delivery.

Speaker Notes:

Greetings esteemed leaders of [Healthcare Organization/Community-Based Care Delivery Service]. Today, I am honored to present on the topic of enhancing care delivery through the exploration of ethical and legal considerations, coupled with the utilization of community resources and best practices. The purpose of this presentation is to delve into the intricacies of care coordination, emphasizing the significance of understanding ethical and legal implications in healthcare delivery. Furthermore, we will underscore the pivotal role of evidence-based interventions and interprofessional collaboration in augmenting patient outcomes and fostering quality care delivery.

Slide 3: Specific Situation

  • Scenario: Optimization of care coordination for elderly patients transitioning from hospital to home care.
  • Objective: Identify and evaluate current organizational or community resources.
  • Resources:
    • Care coordination programs.
    • Home health agencies.
    • Community support initiatives.
  • Tailored services to meet the unique needs of elderly population.

Speaker Notes:

Allow me to introduce a specific scenario germane to our discussion: the optimization of care coordination for elderly patients transitioning from hospital to home care. In this context, our aim is to identify and evaluate current organizational or community resources available to address this critical phase of patient care. These resources may encompass a spectrum of services including but not limited to care coordination programs, home health agencies, and community support initiatives tailored to meet the unique needs of our elderly population.

Slide 4: Legal and Ethical Issues

  • Importance of Addressing Legal and Ethical Considerations:
    • Patient privacy and confidentiality.
    • Informed consent.
  • Challenges:
    • Utilization of health information systems.
    • Compliance with regulatory frameworks (e.g., HIPAA).
  • Strategies for Mitigation:
    • Ensuring patient data integrity.
    • Upholding ethical standards of practice (Kushinka & Kushinka, 2019).

Speaker Notes:

As we navigate the landscape of care coordination, it is imperative to confront the legal and ethical considerations inherent in our practices. The utilization of health information systems for care coordination raises ethical concerns surrounding patient privacy, confidentiality, and informed consent. Moreover, compliance with regulatory frameworks such as the Health Insurance Portability and Accountability Act (HIPAA) poses formidable challenges in safeguarding patient data integrity and upholding ethical standards of practice. Through a comprehensive analysis, we endeavor to elucidate these intricate issues and explore strategies for mitigating associated risks.

Slide 5: Recommendations for Improvement

  • Recommendations:
    • Alignment with ethical and legal imperatives (Dawson & Verweij, 2018).
    • Implementation of evidence-based interventions (McGonigle & Mastrian, 2018).
    • Transformative impact on practice outcomes.
  • Positive Ramifications:
    • Fortifying ethical and legal practices.
    • Enhancing quality and efficacy of care delivery.

Speaker Notes:

Drawing upon our analysis of current practices, we proffer recommendations for improvement aimed at aligning our endeavors with ethical and legal imperatives. By juxtaposing these recommendations against existing practice outcomes or data, we aspire to delineate the transformative impact of implementing evidence-based interventions. It is incumbent upon us to underscore the positive ramifications of these interventions in fortifying ethical and legal practices, thereby enhancing the quality and efficacy of care delivery.

Slide 6: Evidence-Based Intervention

  • Identification of Evidence-Based Interventions:
    • Supported by empirical research (Nelson et al., 2018).
    • Tailored to specific care delivery scenario.
  • Stakeholder Engagement:
    • Healthcare organizations.
    • Care providers.
    • Patients.
    • Caregivers.

Speaker Notes:

In our pursuit of excellence, we turn our attention to evidence-based interventions supported by empirical research. By identifying interventions tailored to our specific care delivery scenario, we lay the groundwork for stakeholder engagement and collaborative partnership. It is paramount to recognize the diverse stakeholders vested in our endeavors, ranging from healthcare organizations to care providers, patients, and caregivers. Through inclusive engagement, we endeavor to foster a synergistic approach towards achieving optimal patient outcomes.

Slide 7: Interprofessional Support

  • Roles and Responsibilities:
    • Various stakeholders involved.
    • Clear delineation for intervention development, implementation, and sustainability (Levett-Jones & Bourgeois, 2017).
  • Principles:
    • Effective communication.
    • Teamwork.

Speaker Notes:

Central to our efforts is the cultivation of interprofessional support and collaboration. By delineating the roles and responsibilities of various stakeholders, we foster a cohesive framework for intervention development, implementation, and sustainability. Effective communication and teamwork emerge as cornerstone principles guiding our collaborative endeavors. It behooves us to acknowledge the instrumental role of interprofessional teams in navigating the complexities of care coordination and driving positive change.

Slide 8: Data Use and Evaluation

  • Utilization of Data:
    • Informed decision-making (The Office of the National Coordinator for Health Information Technology, n.d.).
    • Driving continuous improvement.
  • Baseline Data:
    • Assess current practices and outcomes.
    • Provide insights for intervention effectiveness.
  • Systematic Evaluation:
    • Benchmarking.
    • Ongoing assessment and refinement.

Speaker Notes:

At the heart of our intervention lies the utilization of data-driven insights to inform decision-making and drive continuous improvement. Baseline data serves as a cornerstone for assessing the effectiveness of our intervention, providing invaluable insights into current practices and outcomes. Through systematic evaluation and benchmarking, we chart a course for ongoing assessment and refinement, ensuring alignment with evolving patient needs and best practices in care delivery.

Slide 9: Recommendations for Sustainability

  • Long-term Strategies:
    • Foster a culture of continuous improvement (Kushinka & Kushinka, 2019).
    • Promote organizational resilience and adaptability.
  • Vigilance:
    • Address emergent ethical and legal challenges.
    • Demonstrate foresight and ingenuity.

Speaker Notes:

As we embark on this transformative journey, we must contemplate strategies for sustaining intervention outcomes and fostering a culture of continuous improvement. By articulating recommendations for long-term sustainability, we chart a course for organizational resilience and adaptability. It is incumbent upon us to remain vigilant in our pursuit of excellence, addressing emergent ethical and legal challenges with foresight and ingenuity.

Slide 10: References

HHS. (n.d.). Health information privacy. Retrieved from https://www.hhs.gov/hipaa/index.html

Kushinka, J. E., & Kushinka, M. (2019). Health informatics: Practical guide for healthcare and information technology professionals. CRC Press.

Levett-Jones, T., & Bourgeois, S. (Eds.). (2017). The clinician’s guide to quality and safety in healthcare. Cambridge University Press.

McGonigle, D., & Mastrian, K. G. (2018). Nursing informatics and the foundation of knowledge (4th ed.). Jones & Bartlett Learning.

Nelson, R., Staggers, N., & Health Information Management Systems Society. (2018). Health informatics: An interprofessional approach (2nd ed.). Mosby.

The Office of the National Coordinator for Health Information Technology. (n.d.). What is interoperability? Retrieved from https://www.healthit.gov/topic/interoperability

Detailed Assessment Instructions for the NURS FPX 6616 Community Resources and Best Practices Paper Assignment

Description

Assessment 1 Instructions: Community Resources and Best Practices

Overview:

  • You will develop a presentation consisting of 8 –10 slides for the leaders of a health care organization or community-based care delivery service in which you explore current organizational or community resources for a specific situation related to care delivery.

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

To affect quality care coordination as a leader in practice, you have to understand the outcomes you want to achieve, the best practice that supports the outcomes, the related legal and ethical concerns and how to determine recommendations to produce the outcomes. This includes collaboration with the interprofessional team, data use, and the ability to communicate clearly and precisely.

SHOW MORE

Assessment Instructions

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

Preparation

This assessment requires you to create a presentation and develop a script For each slide as it would be presented. 

  • For tips on creating a PowerPoint presentation, refer to the Effective Presentations section in the Resources for this assessment. Refer to the Using Kaltura tutorials to learn how to use Kaltura to record your presentation.

Note: Remember that you can submit all, or a portion of, your draft care plan to Smarthinking for feedback, before you submit the final version for this assessment. However, be mindful of the turnaround time of 24–48 hours for receiving feedback, if you plan on using this free service.

Context

Using health care information systems to effect change is critical to creating quality outcomes. A leader in practice for care coordination needs to be able to measure and evaluate change using data.

Requirements

You will develop a presentation for the leaders of a health care organization or community-based care delivery service in which you explore current organizational or community resources for a specific situation related to care delivery. Your presentation will include either voice-over or video of you speaking about your presentation to the audience. Your slides should include bulleted points (one line each) that highlight your points for each topic. Your slides should not be text-intensive; put all the details in the speaker notes.

PRESENTATION FORMAT AND LENGTH

At a minimum, your presentation must include the following slides:

  • Purpose (the reasons for your presentation).
  • A specific situation related to care delivery and current organizational or community resources.
  • The legal and ethical issues that can occur due to the current practice.
  • Recommendations for improvement and a comparison to current practice.
  • An evidence-based intervention.
  • Explanation of data use and interprofessional support.
  • References (at the end of your presentation).
  • The content of your presentation should consist of 8–10 slides, not including the title, purpose, and references slides. Do not exceed 10 slides as this could create problems for submitting your work to SafeAssign.

Note: You may vary from the suggestion above, but you must meet all the criteria listed below. Please read the full instructions carefully.

SUPPORTING EVIDENCE

In your presentation:

  • Cite 5–7 sources of credible, scholarly, or professional evidence to support your analysis and recommendations.
  • List your sources on the references slide.

PRESENTATION TOOLS

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 your faculty to avoid potential file compatibility issues.

Use the speaker’s notes section of each slide to develop your talking points and cite your sources, as appropriate. If you need help designing your presentation, 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 software.

You have the option of either recording a voice-over track for your presentation or creating a video of you speaking about your presentation to the audience. In the latter, the presentation will be in the background and you will be on camera. In either case, you may use Kaltura or similar software for your audio or video recording. If using Kaltura, refer to the Using Kaltura tutorials for directions on recording and uploading your media in the courseroom.

Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact DisabilityServices@Capella.edu to request accommodations.

Directions

Note: 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 Community Resources and Best Practices Scoring Guide to better understand how each criterion will be assessed.

For this assessment, you will create a presentation for the leaders of a health care organization or community-based care delivery service to explore current organizational or community resources for a specific situation related to care delivery. Following these instructions will help ensure you meet the scoring guide criteria:

    • Begin your presentation with a description or summary of a specific situation related to care delivery and current practices. Analyze the legal and ethical issues that can occur due to the current practice.
    • Recommend best practices (interventions) and compare against current practice outcomes or data. Include the positive effects of the intervention for the support of ethical and legal practices.
    • Identify an effective evidence-based intervention from existing research applicable to your situation. Define stakeholders, including organizations, settings, and populations affected. Be inclusive when considering the range of stakeholders.
    • Define interprofessional support for the intervention. Explain not only if this includes stakeholders, but also who is responsible in collaboration with care coordination leader for developing, implementing, and sustaining the intervention.
    • Explain how you will measure baseline data. (What data are currently in place? Does current data show if practices are effective? Are benchmarks being met? Is there a gap in practice?) Define the scheduled evaluation periods you will use to monitor and measure data outcomes (for example, systematic evaluations or other).
    • Conclude by developing recommendations to sustain the intervention outcomes for improved practice.

Scoring Guide Criteria

Your assessment should meet the following scoring guide criteria:

  • Analyze the ethical issues pertaining to using health care information systems for care coordination.
  • Evaluate the legal issues of current practices and potential changes.
  • Compare current outcomes to outcomes seen with best practices.
  • Identify an appropriate evidence-based intervention.
  • Define role of stakeholders and interprofessional teams in an intervention.
  • Explain the use of data-driven outcomes, including data measures and evaluation periods.
  • Recommend ongoing practices to sustain outcomes.
  • Communicate effectively in a manner consistent with professional and scholarly expectations.

Additional Requirements

Your assessment should also meet the following requirements:

    • Communication: Communicate in a manner that is scholarly, professional, respectful, and consistent with expectations for professional practice in education. Original work and critical thinking are required regarding your assessment and scholarly writing. Your writing must be free of errors that detract from the overall message.
    • Media presentation: Include 8–10 slides, with notes or a transcript to ensure accessibility to everyone. Upload the presentation.
    • Resources: Include 5–7 scholarly resources, other than the text or articles in the Resources. Include citations at the end of the presentation.
    • APA guidelines: Resources and citations are formatted according to current APA style and format. When appropriate, use APA-formatted headings.
    • Font and font size: Use a professional-looking font of appropriate size and weight for presentation, generally 24–28 points for headings and no smaller than 18 points for bullet-point text.
    • Portfolio Prompt: You may choose to save this learning activity to your ePortfolio.

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NURS FPX 6614 Disseminating the Evidence Scholarly Video Media Submission Paper Example

NURS FPX 6614 Assessment 3 Disseminating the Evidence Scholarly Video Media SubmissionNURS FPX 6614 Assessment 3 Disseminating the Evidence Scholarly Video Media Submission

NURS FPX 6614 Disseminating the Evidence Scholarly Video Media Submission Paper Assignment Brief

Course: NURS-FPX6614 Structure and Process in Care Coordination

Assignment Title: NURS FPX 6614 Assessment 3 Disseminating the Evidence Scholarly Video Media Submission

Assignment Overview

In this assignment, you will produce a 5–8 minute video discussion script of your care coordination intervention for a peer-reviewed media platform. This video will serve as a means to disseminate the outcomes of your intervention and provide recommendations for sustaining its success.

Understanding Assignment Objectives

The primary objective of this assignment is to effectively communicate the findings of your care coordination intervention and provide recommendations for sustaining the achieved outcomes. By creating a scholarly video, you will demonstrate your ability to convey complex information in a professional and accessible manner.

The Student’s Role

As a nursing student, your role in this assignment is to act as a healthcare professional who has successfully implemented a care coordination intervention aimed at addressing a clinical priority. Your task is to present the key findings of your intervention and offer recommendations for future initiatives.

You Can Also Check Other Related Assessments for the NURS-FPX6614 Structure and Process in Care Coordination Course:

NURS FPX6614 Assessment 1 Defining a Gap in Practice Executive Summary Example

NURS FPX 6614 Assessment 2 Enhancing Performance as Collaborators in Care Presentation Example

NURS FPX 6614 Disseminating the Evidence Scholarly Video Media Submission Paper Example

Greetings esteemed colleagues,

I am Jennie Bowlin, and it is my privilege to share with you today the culmination of my intervention and the strategies I propose to sustain its successes. In the realm of nursing, disseminating evidence is the cornerstone of progress, entailing the sharing of research, insights, and outcomes with fellow healthcare professionals (Chambers, 2018). It is the conduit through which innovation and best practices permeate our collective efforts to enhance patient care.

Introduction

Before looking at the details of my intervention, it’s imperative to grasp the foundational elements. The core of my endeavor was to address a pressing clinical concern through evidence-based practice. To achieve this, I posed a PICOT question:

In overweight adults with hypertension, do lifestyle modifications compared to antihypertensive medications result in low blood pressure within 6 months?

This question stems from the recognition of the intricate relationship between obesity and hypertension, both prevalent and interrelated health issues. By examining the efficacy of lifestyle modifications versus medication, I aimed to discern the most effective approach in managing hypertension in this specific population.

Care Coordination Efforts

Introduction to the Issues

Obesity and hypertension often coexist, exacerbating symptoms and complicating management. Research suggests that obesity contributes to a significant portion, around 65 to 78%, of hypertension cases. The accumulation of extra fat tissue in the body can lead to various physiological changes that contribute to or worsen hypertension (Ahmadi et al., 2019). Lifestyle modifications, such as changes in diet and exercise habits, are crucial for managing hypertension effectively. Studies have shown that these lifestyle adjustments yield more favorable outcomes compared to relying solely on antihypertensive medications (Olowofela & Isah, 2018). Given this, my intervention focused on empowering patients with the necessary knowledge and resources to prioritize lifestyle modifications as the primary strategy for managing hypertension.

Promoting Lifestyle Changes for Hypertension Management

Healthcare providers play a pivotal role in educating patients about the benefits of lifestyle changes. By imparting knowledge and promoting behavioral modifications, practitioners can significantly influence patient behavior and empower individuals to take control of their health (Shayesteh et al., 2018). Educational initiatives aimed at raising awareness about the link between lifestyle factors and hypertension are essential for promoting healthier habits and improving disease management among hypertensive patients (Shayesteh et al., 2018).

The PICOT Question

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

Key Care Coordination Efforts

Central to my intervention was the concept of care coordination, a collaborative approach involving a diverse team of healthcare professionals (Kruk et al., 2018). This multidisciplinary team, comprising dietitians, nurses, cardiologists, physiotherapists, and information technologists, worked synergistically to address the multifaceted needs of hypertensive patients. Regular team meetings fostered alignment on patient goals and ensured comprehensive care delivery (Will et al., 2019).

Implications

The adoption of care coordination not only enhances patient outcomes but also aligns with the triple aim of health reform, striving for improved population health, enhanced patient experience, and reduced healthcare costs (Kohl et al., 2018). By leveraging this approach, we endeavor to achieve holistic and sustainable improvements in the management of hypertension among obese individuals.

Change in Practice Related to Services and Resources

Resources

According to the Centers for Disease Control and Prevention (CDC, 2020), healthcare professionals should educate patients about the benefits of making lifestyle changes. This can be achieved through various means such as providing fact sheets, guidelines, social media messages, and handouts.

Services

In the realm of care coordination, nurses and other healthcare professionals play a crucial role in supporting obese hypertensive patients. They offer encouragement and assistance, empowering patients to take control of their health (Hansen et al., 2021). Additionally, as part of a care coordination team, healthcare professionals collaborate to develop personalized care plans tailored to each patient’s needs. Telehealth is also utilized to educate patients on self-management techniques (Hansen et al., 2021).

Key Care Coordination Efforts

Team-based care is essential for achieving goals related to value-based care and ensuring a positive patient experience. Recognizing that multiple stakeholders are involved in a patient’s care, team-based care emphasizes collaboration among healthcare providers. Multidisciplinary team meetings, where medical practitioners from various specialties come together, facilitate discussions on patient conditions and diagnoses. These sessions aim to align treatment plans with evidence-based guidelines, ultimately enhancing patient outcomes and inter-professional communication (Rollet et al., 2021).

Efforts to Build Stakeholder Engagement

Efforts to Build Stakeholder Engagement are foundational to successful practice change, requiring a systematic approach to identify, assess, and address stakeholder needs (Sperry & Jetter, 2019). By fostering open communication and collaboration, we ensure that all voices are heard and valued in the pursuit of shared goals. This process involves systematically identifying, evaluating, organizing, and executing actions to influence stakeholders, analyzing each stakeholder’s needs and demands to ensure their requirements are addressed.

Leading the Change in Practice

Leading the Change in Practice demands strategic leadership and effective communication, utilizing Kurt Lewin’s change theory to guide interventions for obese hypertensive patients (McFarlan et al., 2019). This theory delineates three sequential steps: unfreezing, changing, and refreezing. Initially, stakeholders are identified and engaged through team meetings to establish intervention objectives and address their requirements. Subsequently, interventions are implemented, and patients are educated about lifestyle changes during the change phase. Finally, stakeholders play a vital role in monitoring patients’ adherence to the advised lifestyle changes, ensuring sustained adherence and successful outcomes (McFarlan et al., 2019).

Encouraging and Building Stakeholder Engagement

Organizations should establish a robust stakeholder engagement strategy to understand and address stakeholder concerns effectively. Creating a stakeholder engagement plan is the initial step, outlining pertinent stakeholders, the necessity of their involvement, the approach to engaging them, and the objectives to pursue (Boaz et al., 2018). It is crucial to respect stakeholders’ needs, interests, and views to keep them engaged throughout the process. Informing stakeholders about the proposed changes, their benefits, and providing avenues for addressing their queries are essential for effective communication and maintaining stakeholder engagement (Boaz et al., 2018).

Recommendations for Sustainability and Future Initiatives

How to Sustain Current Outcomes

Sustaining positive outcomes necessitates ongoing interprofessional collaboration, patient engagement, and continuous quality improvement efforts (Kruk et al., 2018). Regular team meetings, enhanced communication channels, and a patient-centric approach are integral to maintaining the gains achieved through our intervention.

Recommendations on Moving Forward

Looking ahead, several strategies can further enhance care coordination and optimize patient outcomes:

  • Develop a comprehensive stakeholder engagement plan to ensure alignment and commitment.
  • Prioritize stakeholder needs and preferences to foster a culture of inclusivity and collaboration.
  • Utilize SMART goals to set actionable and measurable targets for patient care.
  • Employ the Plan-Do-Study-Act cycle to iteratively improve care processes and outcomes.
  • Embrace technology to facilitate seamless interprofessional communication and data sharing.

Conclusion

In conclusion, the integration of evidence-based practice in nursing interventions, as evidenced in the case of managing hypertension among obese individuals, highlights the importance of systematic approaches to care coordination and stakeholder engagement. Prioritizing lifestyle modifications over medications and leveraging multidisciplinary team collaboration are key strategies for improving patient outcomes and promoting sustainable health practices. Moving forward, sustained efforts in stakeholder engagement, ongoing education, and the integration of technology will be essential for maintaining the gains achieved and advancing future initiatives in hypertension management. Disseminating evidence in nursing goes beyond mere information sharing; it serves as the catalyst for innovation and the optimization of patient care. Through collective efforts grounded in evidence-based practice and interdisciplinary collaboration, we aim to enhance the health outcomes of our patients and communities.

References

Boaz, A., Hanney, S., Jones, T., & Soper, B. (2018). Does the engagement of clinicians and organisations in research improve healthcare performance: a three-stage review. BMJ Open, 8(3), e018735.

CDC. (2020). Rethinking blood pressure: What healthcare providers should tell their patients about high blood pressure. Retrieved from https://www.cdc.gov/dhdsp/clinical-resources/physician-resources/rethinking-blood-pressure.html

Chambers, D. (2018). Advancing the science of dissemination and implementation in behavioral medicine: Evidence and progress. Annals of Behavioral Medicine, 52(10), 856-862.

Hansen, A. R., Fonder, M. A., & Sherburne, A. (2021). Virtual health care delivery to hypertensive adults: A case report. Journal of Nurse Practitioners, 17(1), 59-62.

Kohl, S., Gabel, P., & Tritz, D. (2018). Care coordination for the obese hypertensive patient: a framework for nurse practitioners. Journal of the American Association of Nurse Practitioners, 30(7), 355-363.

Kruk, M. E., Gage, A. D., Joseph, N. T., Danaei, G., García-Saisó, S., Salomon, J. A., … & Grepin, K. A. (2018). Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. The Lancet, 392(10160), 2203-2212.

McFarlan, L., Li, C., & Lau, M. (2019). Changing healthcare provider attitudes toward the obese hypertensive patient using Lewin’s change theory. Journal of the American Association of Nurse Practitioners, 31(4), 1-7.

Rollet, K. M., Shulman, K. M., & Martinez, E. J. (2021). Multidisciplinary team rounds enhance patient care: A systematic review. Journal of Hospital Medicine, 16(5), 306-310.

Shayesteh, S., Paganoni, S., & Khan, A. (2018). Can lifestyle modification influence hypertension awareness and behavior in a primary care practice? Journal of the American Association of Nurse Practitioners, 30(11), 648-654.

Sperry, R., & Jetter, J. (2019). Developing a stakeholder engagement strategy in health information technology projects: Lessons learned from California’s Medicaid meaningful use program. Journal of Medical Internet Research, 21(1), e11763.

Will, J. J., McCauley, A. K., & Mullan, P. (2019). Multidisciplinary teams improve patient outcomes: comprehensive care for chronic diseases. Journal of the American Association of Nurse Practitioners, 31(1), 37-41.

 

****Thank you for your attention and dedication to advancing the field of healthcare through evidence and collaboration.****

Detailed Assessment Instructions for the NURS FPX 6614 Disseminating the Evidence Scholarly Video Media Submission Paper Assignment

Description

Assessment 3 Instructions: Disseminating the Evidence Scholarly Video Media Submission

At the completion of your intervention, you will produce a 5–8 minute video discussion script of your care coordination intervention for a peer-reviewed media platform. 
As an advanced practice health care provider, it’s likely that you will be asked to give a presentation at some point in your career. Now that you have completed this project, it’s time to disseminate the outcomes in the form of a recorded professional presentation. A professional presentation style requires the confidence and ability to convey the right image that you want your audience to see. Unfortunately, it’s easy to miss some of the opportunities available to help you present yourself in the best possible light and, as a result, enjoy the success you deserve. Remember to be forthright about what happened during the project and about how data were collected and analyzed, and present the findings so stakeholders and external parties clearly understand the steps in the process. By completing this final activity, you can help others recreate this type of project and enhance outcomes in other patient care settings.

Assessment Instructions

In Assessment 3, you will build on the work you completed in Assessments 1 and 2.
Assignment Summary
This assessment requires you to prepare a 5–8 minute video discussion script of your care coordination intervention. Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact DisabilityServices@Capella.edu to request accommodations. If you are unable to record a video, please contact your faculty member as soon as possible to explore options for completing the assessment.
You have completed the intervention and achieved enhanced outcomes. Now you need to disseminate your findings and provide recommendations to sustain the results of your intervention. You have been asked by nursing leadership to produce a scholarly video for a peer-reviewed media platform. The video will include 5–8 minutes of scholarly discussion covering the topics listed below.
Grading Criteria
The numbered assignment instructions outlined below correspond to the grading criteria in the Disseminating the Evidence Scholarly Video Media Submission 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 care coordination efforts related to clinical priorities based on a PICOT question. 
    • Provide the PICOT question and a brief introduction of the issues.
  2. Describe the change in practice related to services and resources that will be available for the interprofessional care coordination team. 
    • Describe the key care coordination efforts.
  3. Explain efforts to build stakeholder engagement within the interprofessional team. 
    • How did you lead the change in practice?
    • Summarize how you encouraged and built stakeholder engagement.
  4. Recommend next steps that that support thoughtful resource utilization and a safe environment in care coordination. 
    • Propose how you will sustain the current outcomes with the coordinated care interprofessional team.
    • Make recommendations on moving forward that support thoughtful resource utilization and a safe environment.
  5. Produce a video that provides insight, understanding, and reflective thought about care coordination.
  6. Communicate audibly and professionally, using proper grammar and including a reference list formatted in current APA style.
  7. Important Note: but do address each scoring guide criterion in the video, including a discussion of authors in the literature who support the ideas presented. Please submit a separate APA-formatted reference list for the resources discussed in your reflection.
    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.

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NURS FPX 6614 Enhancing Performance as Collaborators in Care Presentation Example

NURS FPX 6614 Assessment 2 Enhancing Performance as Collaborators in Care PresentationNURS FPX 6614 Assessment 2 Enhancing Performance as Collaborators in Care Presentation

Assignment Brief: NURS FPX 6614 Enhancing Performance as Collaborators in Care Presentation Assignment

Course: NURS-FPX6614 Structure and Process in Care Coordination

Assignment Title: NURS FPX 6614 Assessment 2 Enhancing Performance as Collaborators in Care Presentation

Assignment Overview

In this assignment, you will leverage your gap analysis to deliver a 12-15 slide recorded PowerPoint presentation highlighting the critical importance of interprofessional collaboration for ensuring safe, high-quality coordinated care. As a leader in practice, your presentation will serve as a guide to stakeholders, providing them with a comprehensive understanding of the steps involved in fostering positive interprofessional communication and collaboration to achieve better health outcomes.

Understanding Assignment Objectives

The primary objective of this assignment is to demonstrate proficiency in analyzing clinical priorities, evaluating available services and resources, creating effective interprofessional collaboration strategies, proposing care coordination processes, and communicating effectively as a scholar-practitioner.

The Student’s Role

As a student, your role is to act as a leader in practice, guiding stakeholders through the process of enhancing interprofessional collaboration for improved patient care outcomes. Your presentation will serve as a tool to educate, inform, and engage stakeholders, fostering transparency and understanding about the proposed changes needed for the improvement project.

Competencies Measured

This assignment measures the following competencies:

  • Analyzing Clinical Priorities: Analyze steps to improve interprofessional collaboration in evidence-based practice for population care.
  • Evaluating Potential Services and Resources: Explain the educational services and resources selected for the population receiving care.
  • Creating Effective Interprofessional Collaboration Strategies: Summarize plans to collaborate and partner with interprofessional team members.
  • Proposing Care Coordination Processes: Propose the outcomes of the new process for improved interprofessional collaboration and describe any ethical considerations supporting change for the specific population with services and resources.
  • Communicating Effectively: Create a professional presentation that can be used to run a working session of an interprofessional team meeting. Write content clearly and logically, with correct use of grammar, punctuation, and mechanics.

You Can Also Check Other Related Assessments for the NURS-FPX6614 Structure and Process in Care Coordination Course:

NURS FPX6614 Assessment 1 Defining a Gap in Practice Executive Summary Example

NURS FPX 6614 Assessment 3 Disseminating the Evidence Scholarly Video Media Submission Example

NURS FPX 6614 Enhancing Performance as Collaborators in Care Presentation Example

Title Slide: Enhancing Performance as Collaborators in Care Presentation

Subtitle: The Critical Importance of Interprofessional Collaboration for Safe, High-Quality Coordinated Care

Speaker: Jennie Bowlin

Date: [Insert Date]

Write the information below as an elaborative slide with bullets and brief illustrations:

Slide 1: Introduction

  • Welcome: Esteemed colleagues, I extend a warm invitation to each one of you present here today.
  • Assembly: Let me introduce the diverse assembly before us: nurses, physicians, hospital administrators, nutritionists, physiotherapists, and information technologists.
  • Objective: Our collective endeavor today is to delve into the significance of interprofessional collaboration in addressing the healthcare needs of overweight hypertensive patients.
  • Multidisciplinary Approach: Through this multidisciplinary approach, we aim to educate and empower these patients towards embracing healthier lifestyles.

Slide 2: Background

  • Obesity and Hypertension: These conditions often coexist, presenting a complex challenge in patient care.
  • Role of Pharmacological Interventions: While pharmacological interventions play a vital role, studies indicate that patients may experience adverse effects from medications within the initial stages.
  • Alternative Approach: Lifestyle modifications such as dietary improvements and regular exercise have shown to effectively reduce blood pressure and body weight without adverse effects (Cosimo Marcello et al., 2018).
  • Importance of Collaboration: Hence, it is imperative for healthcare providers to collaborate and devise strategies to educate patients on making healthier lifestyle choices, thereby improving their overall well-being.

Slide 3: Pathway to Improving Inter-professional Collaboration

Overview to Enhance Evidence-based Practice:

  • Advancements in Medical Research: Every day, advancements in medical research contribute to refining treatment modalities and enhancing patient care.
  • Updated Guidelines: New evidence emerges regularly, providing healthcare providers with updated guidelines and approaches to optimize patient outcomes (O’Cathain et al., 2019).
  • Crucial Importance: Therefore, fostering evidence-based practice among healthcare professionals is crucial.

Steps to Improve Evidence-based Practice:

  • Training: Providing adequate training in evidence-based practices is essential for healthcare professionals.
  • Access to Research Resources: Facilitating access to research resources such as journals, databases, and libraries can support healthcare providers in staying updated with the latest evidence.
  • Culture of Continuous Learning: Fostering a culture of continuous learning and knowledge exchange within healthcare organizations encourages professionals to stay updated with the latest research findings and integrate them into practice.

Slide 4: Explanation of the Planning Stage

To effectively enhance evidence-based practice and promote interprofessional collaboration, several key steps can be undertaken:

  • Formation of Interprofessional Teams: Establish multidisciplinary teams comprising nurses, physicians, nutritionists, physiotherapists, hospital administrators, and IT specialists to devise comprehensive care strategies (Lafuente-Lafuente et al., 2019).
  • Appointment of Team Leaders: Designate competent leaders within each team to guide the collaborative effort and ensure adherence to evidence-based practices.
  • Regular Team Meetings: Conduct regular meetings to facilitate communication, align goals, and brainstorm innovative solutions tailored to the needs of overweight hypertensive patients.

 Slide 5: Educational Services and Resources

Educational Methodologies:

  • Empowering Patients: Effective educational strategies are essential for empowering patients to make informed decisions about their health.
  • Leveraging Health Information Technology (HIT): Utilizing HIT, such as telehealth, enables healthcare professionals to remotely educate and monitor patients regarding lifestyle modifications and medication adherence (Chike-Harris et al., 2021).

Strategies for Effective Patient Education:

  • Understanding Learning Styles: Understanding each patient’s preferred learning style and adapting educational materials accordingly enhances engagement and comprehension.
  • Considering Abilities and Limitations: Additionally, considering patients’ abilities and limitations ensures that educational interventions are inclusive and effective.

Slide 6: Collaborate and Partner with Inter-professional Team Members

Implementation Process:

  • Chronic Care Model (CCM): The implementation of the Chronic Care Model (CCM) facilitates comprehensive care coordination for chronic conditions like obesity and hypertension.
  • Thorough Assessments: Through CCM, healthcare providers can conduct thorough assessments to understand the patient’s condition and needs.
  • Patient Involvement: Involving patients in treatment planning empowers them to actively participate in their care and decision-making process.
  • Clear Communication Channels: Establishing clear communication channels within the care coordination team ensures effective information sharing and collaboration (Lee & Bae, 2018).

Collaborative Care Coordination:

  • Multidisciplinary Team: The care coordination team comprises various healthcare professionals, including physicians, nurses, nutritionists, physiotherapists, and the patient’s family.
  • Personalized Care: Collaborating with inter-professional team members allows for the delivery of personalized care tailored to the patient’s unique needs and preferences.
  • Effective Monitoring: By working together, the care coordination team can effectively monitor patient progress, adjust treatment plans as needed, and ensure continuity of care.

 Slide 7: Plans to Collaborate and Partner

Fostering Collaboration:

  • Conducive Social Platform: Creating a conducive social platform where team members can connect, share ideas, and collaborate is essential for fostering teamwork (Schmutz et al., 2019).
  • Regular Interactions: Facilitating regular interactions through meetings, brainstorming sessions, or team huddles encourages communication and collaboration among team members.

Enhancing Collaboration through Technology:

  • Integration into Routine Activities: Integrating collaboration into routine activities ensures that teamwork becomes a natural part of daily workflows.
  • Leveraging Technology: Leveraging technology tools such as collaboration platforms, messaging apps, or telehealth systems facilitates seamless communication and information sharing among team members.

Slide 8: Outcomes of the New Process

Results Assessments:

  • Evaluation Criteria: Evaluation of the proposed strategy will be based on the OECD’s six assessment criteria: relevance, coherence, effectiveness, efficiency, impact, and sustainability (OECD, 2021).
  • Expected Outcomes: Furthermore, successful interprofessional collaboration is expected to yield positive outcomes for overweight hypertensive patients.

Expected Positive Outcomes:

  • Improved Patient Education: Enhanced educational strategies and collaborative efforts are anticipated to result in better patient understanding and knowledge retention.
  • Adherence to Lifestyle Modifications: Effective collaboration and patient engagement are expected to improve adherence to recommended lifestyle modifications such as diet and exercise.
  • Better Health Outcomes: Ultimately, these efforts aim to improve overall health outcomes for overweight hypertensive patients, leading to better management of their conditions and improved quality of life.

Slide 9: Academic Proof

Numerous Studies:

  • Significance of Interprofessional Collaboration: Numerous studies underscore the significance of interprofessional collaboration in improving patient outcomes.
  • Ansa et al. (2020): Ansa et al. emphasize the role of collaboration in optimizing healthcare delivery and enhancing patient satisfaction.
  • Arenson and Brandt (2021): Similarly, Arenson and Brandt highlight the importance of teamwork in achieving patient-centered care and fostering positive healthcare experiences.

Supporting Evidence:

  • Improved Healthcare Delivery: Research findings support the notion that effective collaboration among healthcare professionals leads to improved healthcare delivery and patient outcomes.
  • Patient Satisfaction: Studies indicate that interprofessional collaboration contributes to higher levels of patient satisfaction by ensuring coordinated and comprehensive care.

Slide 10: Ethical Considerations

Ethical Principles:

  • Patient Autonomy: Upholding ethical principles involves prioritizing patient autonomy, allowing individuals to make informed decisions about their healthcare.
  • Confidentiality: Maintaining confidentiality is crucial to respecting patients’ privacy rights and building trust between healthcare providers and patients (Varkey, 2021).

Cultural Sensitivity:

  • Respecting Diversity: Acknowledging and respecting the diverse backgrounds and beliefs of both patients and healthcare team members is essential.
  • Fostering Trust: Cultural sensitivity fosters trust and strengthens collaborative relationships, leading to improved patient outcomes and satisfaction.

Slide 11: Conclusion

In conclusion, effective interprofessional collaboration is indispensable in addressing the complex healthcare needs of overweight hypertensive patients. By implementing evidence-based practices, leveraging educational resources, and fostering a culture of collaboration, we can empower patients to embrace healthier lifestyles and achieve improved health outcomes (Schommer et al., 2018). Let us continue to work together synergistically to deliver patient-centered care and promote holistic well-being.

Slide 11: Conclusion

  • Interprofessional Collaboration: Effective interprofessional collaboration is indispensable in addressing the complex healthcare needs of overweight hypertensive patients.
  • Implementation of Evidence-based Practices: By implementing evidence-based practices and leveraging educational resources, we can empower patients to embrace healthier lifestyles.
  • Fostering a Culture of Collaboration: Fostering a culture of collaboration among healthcare professionals enhances patient care and improves health outcomes (Schommer et al., 2018).

Promoting Holistic Well-being:

  • Empowering Patients: Empowering patients to take control of their health and well-being by providing them with the necessary knowledge and support.
  • Achieving Improved Health Outcomes: Through collaborative efforts, we can achieve improved health outcomes and promote holistic well-being for overweight hypertensive patients.

Slide 12: References

Ansa, B. E., Zechariah, S., Gates, A. M., Johnson, S. W., Heboyan, V., & De Leo, G. (2020). Attitudes and behavior towards interprofessional collaboration among healthcare professionals in a large academic medical center. Healthcare, 8(3), 323.

Arenson, C., & Brandt, B. F. (2021). The importance of interprofessional practice in family medicine residency education. Family Medicine.

Chike-Harris, K., Cook, C., Gamboa, C., & Dent, S. (2021). COVID-19 pandemic: Embracing telemedicine, patient education, and evidence-based practice. Journal of Medical Internet Research, 23(2), e25992.

Cosimo Marcello, I., Luisa, C., Gianni, P., Mario, M., Margherita, F., & Olga, T. (2018). Evidence-based medicine: What it is and what it is not. Clinical Cases in Mineral and Bone Metabolism, 15(2), 161–164.

Lafuente-Lafuente, C., Leitao, C., Kilani, I., Dublanc, S., & Bergmann, J. F. (2019). Interventions for preventing thromboembolism in patients with atrial fibrillation: A systematic review. BMC Family Practice, 20(1), 1-15.

Lee, J., & Bae, S. H. (2018). The role of nursing informatics on promoting evidence-based practice. Journal of Nursing Scholarship, 50(5), 563-571.

OECD. (2021). Measuring the quality of health care across OECD countries. OECD Publishing.

Schmutz, J. B., Meier, L. L., Manser, T., & Wehner, T. (2019). The power of opposites: How teams with dissimilar members manage team processes and performance in healthcare organizations. Health Services Research, 54(S2), 417-429.

Schommer, J. C., Mueller, B. A., & Biesemeier, D. (2018). Team collaboration: Nurses and pharmacists. In R. Boyer & L. P. VanGraafeiland (Eds.), A new era in pharmacy practice: Integration and expansion (pp. 71–89). American Society of Health-System Pharmacists.

Varkey, P. (2021). The importance of ethics in interprofessional collaboration. Journal of Interprofessional Care, 35(2), 173-174.

Detailed Assessment Instructions for the NURS FPX 6614 Enhancing Performance as Collaborators in Care Presentation Assignment

Description

Assessment 2 Instructions: Enhancing Performance as Collaborators in Care Presentation

As a leader in practice, you will use your gap analysis to provide a 12-15 slide recorded PowerPoint presentation on the critical importance of interprofessional collaboration for the provision of safe, high-quality coordinated care.

Introduction

To gain help and support for your implementation of your project, it is important to guide the stakeholders through all the steps in the process. Providing the team with a detailed cohesive presentation will enhance their understanding and give a voice to any divergent opinions about the proposed changes. This type of engagement creates a platform of transparency about the coming changes needed for the improvement project. Fostering positive interprofessional communications with project stakeholders builds trust and understanding, which in turn leads to better health outcomes.

Preparation

Read the following:

. Standard 6: Evaluation.

. Standard 7: Ethics.

. Standard 8: Education.

. Standard 9: Research and Evidence-Based Practice.

. Standard 10: Performance Improvement.

. Standard 11: Communication.

. Standard 12: Leadership.

. Standard 13: Collaboration.

. Standard 14: Professional Practice Evaluation.

Assessment Summary

Now that you defined a gap in practice and started to involve your stakeholders it is time to do a presentation on the critical importance of interprofessional collaboration for the provision of safe, high-quality coordinated care. As a leader in practice, you will use your gap analysis to provide a 10–12 slide recorded PowerPoint presentation.

Grading Criteria

The numbered instructions outlined below correspond to the grading criteria in the Enhancing Performance as Collaborators in Care Presentation 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 steps to improve interprofessional collaboration in an evidence-based practice for population care.

. Provide an overview of what needs to happen to enhance evidence-based practice.

. Provide an explanation of the planning stages.

  • Explain the educational services and resources selected for the population receiving care.

. What are the education strategies you plan to use with the population receiving the care?

  • Summarize plans to collaborate and partner with interprofessional team members.

. What is the implementation process for the improved care coordination process?

. What are your plans to collaborate and partner with the interprofessional team members?

  • Propose the outcomes of the new process for improved interprofessional collaboration.

. How you will evaluate the outcomes of the new process change?

. Provide scholarly evidence that validates the needed change.

  • Use the scope and standards of practice for care coordination to describe any ethical considerations that supporting the need for change related to services and resources for the specific population. 

. Include information about the ethics that support the process change.

  • Create a professional presentation that can be used to run a working session of an interprofessional team meeting.

. Include a minimum of 5–7 scholarly sources.

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

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. Refer to Evidence and APA for more information.

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 steps to improve interprofessional collaboration in an evidence-based practice for population care.

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

. Explain the educational services and resources selected for the population receiving care.

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

. Summarize plans to collaborate and partner with interprofessional team members.

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

. Propose the outcomes of the new process for improved interprofessional collaboration.

. Use the scope and standards of practice for care coordination to describe any ethical considerations supporting change for the specific population with services and resources.

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

. Create a professional presentation that can be used to run a working session of an interprofessional team meeting.

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

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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 SummaryNURS 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.

You Can Also Check Other Related Assessments for the NURS-FPX6614 Structure and Process in Care Coordination Course:

NURS FPX 6614 Assessment 2 Enhancing Performance as Collaborators in Care Presentation Example

NURS FPX 6614 Assessment 3 Disseminating the Evidence Scholarly Video Media Submission Example

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:

. 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 Cost Savings Analysis Paper Example

NURS FPX 6612 Assessment 4 Cost Savings AnalysisNURS FPX 6612 Assessment 4 Cost Savings Analysis

NURS FPX 6612 Cost Savings Analysis Paper Assignment Brief

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

Assignment Title: NURS FPX 6612 Assessment 4 Cost Savings Analysis

Assignment Instructions Overview

In this assignment, you will conduct a cost savings analysis focusing on the efficiency gains attributable to care coordination within a healthcare setting over the course of one fiscal year. Your task involves compiling cost savings data into a spreadsheet and presenting your key findings in an executive summary. The assessment aims to evaluate your understanding of how care coordination can positively impact the financial health of an organization, improve patient outcomes, and enhance the collection of evidence-based data.

Understanding Assignment Objectives

The primary objective of this assignment is to assess your proficiency in applying care coordination models to improve the patient experience, promote population health, and reduce costs within a healthcare setting. By analyzing cost savings data and presenting key findings, you will demonstrate your ability to communicate effectively with diverse audiences and support your claims with relevant evidence.

The Student’s Role

As the senior care coordinator in your organization, you are tasked with examining and reporting on how care coordination can generate cost savings, improve outcomes, enhance evidence-based data collection, and improve healthcare quality for the community. You will compile cost savings data in a well-organized spreadsheet and create an executive summary to present your analysis to your manager.

Competencies Measured

This assignment measures the following competencies:

  • Apply care coordination models: Describe ways in which care coordination can generate cost savings.
  • Explain the relationship between care coordination and evidence-based data: Describe how care coordination efforts can enhance the collection of evidence-based data and improve quality through the application of an emerging healthcare model.
  • Use health information technology: Explain how care coordination can promote improved health consumerism and effect positive health outcomes.
  • Communicate effectively: Present cost savings data and information clearly and accurately, supporting main points, claims, and conclusions with relevant and credible evidence, and correctly formatting citations and references using APA style.

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 3 Patient Discharge Care Planning Example

NURS FPX 6612 Cost Savings Analysis Paper Example

Introduction

In the ever-evolving landscape of healthcare, the importance of effective care coordination cannot be overstated. Care coordination, involving seamless collaboration among healthcare providers across different settings, has emerged as a pivotal strategy not only for improving patient outcomes but also for achieving cost savings within healthcare organizations. This paper focuses on the diverse nature of care coordination, exploring its role in generating cost savings, promoting health consumerism, and facilitating the collection of evidence-based data. Through an analysis of various approaches and case studies, this paper aims to provide insights into how healthcare organizations can leverage care coordination to optimize financial resources while enhancing the quality of care.

Cost Savings through Care Coordination

One of the primary objectives of care coordination is to streamline healthcare delivery processes to achieve better outcomes at reduced costs. Several key avenues exist through which care coordination can yield significant cost savings:

  • Enhanced Communication and Collaboration: Poor communication among healthcare providers often leads to redundant tests, procedures, and avoidable hospitalizations, driving up healthcare costs. By facilitating seamless communication and collaboration among various stakeholders, care coordination mitigates these inefficiencies, resulting in cost savings. Studies have shown that improved communication can substantially reduce unnecessary healthcare utilization and associated expenditures (Breckenridge et al., 2019).
  • Prevention of Medical Errors: Medical errors not only jeopardize patient safety but also incur substantial financial costs for healthcare organizations. Through proactive care coordination efforts, such as medication reconciliation and standardized care pathways, healthcare providers can minimize the occurrence of medical errors, thereby reducing the associated costs. For instance, the implementation of electronic health records (EHRs) has been shown to significantly decrease medication errors and their corresponding financial implications (Rodziewicz & Hipskind, 2022).
  • Optimal Resource Utilization: Care coordination facilitates the efficient allocation of resources by ensuring that patients receive the right care, in the right setting, at the right time. By avoiding unnecessary hospital admissions, emergency department visits, and prolonged lengths of stay, healthcare organizations can achieve substantial cost savings while maintaining quality of care. Integrated care models, which emphasize comprehensive, patient-centered approaches, have been particularly effective in optimizing resource utilization and reducing overall healthcare expenditures (Rocks et al., 2020).
  • Proactive Chronic Disease Management: Chronic diseases impose a significant economic burden on healthcare systems worldwide. Care coordination plays a pivotal role in managing chronic conditions through proactive monitoring, patient education, and adherence to evidence-based treatment protocols. By preventing disease exacerbations and complications, care coordination reduces the need for costly interventions such as hospitalizations and emergency care, resulting in long-term cost savings (Khullar & Chokshi, 2018).
  • Leveraging Health Information Technology (HIT): The integration of HIT tools, such as electronic medical records and telehealth platforms, into care coordination processes can streamline workflows, improve data accessibility, and enhance decision-making. By leveraging HIT solutions, healthcare organizations can automate administrative tasks, reduce documentation errors, and facilitate real-time communication among care team members, leading to operational efficiencies and cost savings (Wilt et al., 2020).

Health Consumerism and Positive Health Outcomes

In today’s healthcare landscape, empowered consumers seek transparency, convenience, and personalized experiences in their healthcare journeys. Care coordination plays a pivotal role in meeting these evolving consumer expectations while driving positive health outcomes:

  1. Patient-Centric Care Delivery: Care coordination emphasizes a patient-centric approach, wherein healthcare services are tailored to meet individual needs and preferences. By involving patients as active participants in their care journey, care coordination fosters a sense of empowerment and engagement, leading to improved health outcomes and greater satisfaction. Patients who feel supported and involved in decision-making are more likely to adhere to treatment plans and achieve better clinical results (Taylor, 2019).
  2. Seamless Care Transitions: For patients with complex healthcare needs, transitions between different care settings can be challenging and fraught with potential risks. Care coordination ensures seamless transitions across the care continuum, facilitating the exchange of information, continuity of care, and collaboration among providers. By minimizing care fragmentation and preventing gaps in care, care coordination enhances patient safety and reduces adverse events, ultimately leading to improved health outcomes (Hannigan et al., 2018).
  3. Empowerment through Health Education: Education is a cornerstone of effective care coordination, empowering patients to make informed decisions about their health and well-being. Through targeted health education initiatives, care coordinators provide patients with the knowledge and resources they need to manage their conditions, navigate the healthcare system, and adopt healthy lifestyle behaviors. By promoting health literacy and self-management skills, care coordination enables patients to take control of their health, resulting in improved outcomes and reduced healthcare utilization (Karam et al., 2021).
  4. Personalized Care Plans: Care coordination involves the development of individualized care plans that take into account each patient’s unique needs, preferences, and circumstances. By tailoring care interventions to the specific requirements of each patient, care coordinators optimize treatment efficacy, minimize unnecessary interventions, and promote patient engagement. Personalized care plans enhance patient satisfaction, adherence to treatment regimens, and overall health outcomes, contributing to a more consumer-centric healthcare experience (Khullar & Chokshi, 2018).
  5. Accessibility and Convenience: In an era of digital transformation, consumers expect healthcare services to be accessible, convenient, and responsive to their needs. Care coordination leverages technology-enabled solutions such as telemedicine, mobile health apps, and remote monitoring devices to deliver care beyond traditional brick-and-mortar settings. By expanding access to care and reducing barriers to engagement, care coordination enhances patient convenience and satisfaction, driving positive health outcomes and fostering long-term loyalty (Rocks et al., 2020).

Implementing Evidence-Based Care Coordination Models

To maximize the benefits of care coordination and achieve sustainable cost savings, healthcare organizations must implement evidence-based models that align with their unique needs and priorities. Several key strategies can enhance the effectiveness of care coordination efforts:

  • Interdisciplinary Collaboration: Effective care coordination requires collaboration among diverse healthcare professionals, including physicians, nurses, social workers, pharmacists, and allied health professionals. By fostering interdisciplinary teamwork and communication, healthcare organizations can optimize care delivery processes, minimize redundancies, and improve patient outcomes. Interdisciplinary care teams facilitate holistic assessments, shared decision-making, and coordinated interventions, resulting in comprehensive, patient-centered care (Breckenridge et al., 2019).
  • Standardized Care Pathways: Standardized care pathways outline evidence-based guidelines and protocols for managing specific health conditions or procedures. By standardizing care delivery processes and promoting best practices, healthcare organizations can reduce variations in care, enhance quality and safety, and achieve cost savings. Care coordination efforts should prioritize the development and implementation of standardized care pathways across relevant clinical specialties, ensuring consistency, efficiency, and adherence to evidence-based standards of care (Rodziewicz & Hipskind, 2022).
  • Health Information Exchange (HIE): Health Information Exchange (HIE) platforms facilitate the seamless sharing of patient information across different healthcare settings and systems. By enabling interoperability and data exchange, HIE platforms support care coordination efforts by providing timely access to relevant clinical information, reducing duplication of tests and procedures, and enhancing care continuity. Healthcare organizations should invest in robust HIE infrastructure and participate in regional or national HIE networks to facilitate coordinated care delivery and optimize resource utilization (Taylor, 2019).
  • Patient Engagement Technologies: Patient engagement technologies, such as patient portals, mobile apps, and remote monitoring devices, empower patients to actively participate in their care and self-management. By facilitating real-time communication, education, and health tracking, these technologies promote patient engagement, adherence to treatment plans, and early detection of health issues. Healthcare organizations should leverage patient engagement technologies as integral components of care coordination initiatives, tailoring solutions to meet the diverse needs and preferences of their patient populations (Wilt et al., 2020).
  • Data Analytics and Performance Monitoring: Data analytics tools enable healthcare organizations to analyze large volumes of clinical and operational data, identify trends, and measure performance against key metrics. By leveraging data analytics, care coordinators can identify opportunities for process improvement, monitor patient outcomes, and evaluate the effectiveness of care coordination interventions. Healthcare organizations should invest in robust data analytics infrastructure and establish performance monitoring mechanisms to track the impact of care coordination efforts on cost savings, quality improvement, and patient satisfaction (Hannigan et al., 2018).

Cost Savings Data and Analysis

To demonstrate the tangible impact of care coordination on cost savings, healthcare organizations must collect and analyze relevant data on key performance indicators. The following hypothetical scenario illustrates how care coordination initiatives, particularly the implementation of electronic health records (EHRs), can yield substantial cost savings within a healthcare setting:

Table 1: Comparison of Staffing Levels before and after EHR Implementation

Role Before EHR Implementation After EHR Implementation
Registered Nurses 80 20
Care Manager 75 25
Care Coordinator 70 30
Nursing Heads 65 35

 

***Source: Adapted from Hypothetical Data

The implementation of EHRs resulted in significant reductions in staffing levels across various roles within the healthcare organization. By streamlining documentation processes and automating administrative tasks, EHRs enabled healthcare providers to operate more efficiently, thereby reducing labor costs.

Table 2: Comparison of Key Performance Metrics before and after EHR Implementation

Metric Manual Records Documentation EHR Implementation (%) Overall Savings ($)
Medication Errors 95 5 300,000
Drug Complications 90 6 200,000
Hospitalizations 85 10 500,000
Post-discharge Cases 88 12 100,000

 

***Source: Adapted from Hypothetical Data

Furthermore, the transition from manual records documentation to EHRs led to substantial reductions in medication errors, drug complications, hospitalizations, and post-discharge cases. By improving data accuracy, facilitating real-time information exchange, and supporting clinical decision-making, EHRs contributed to enhanced patient safety and reduced healthcare utilization, resulting in significant cost savings for the organization.

Conclusion

In conclusion, effective care coordination holds immense potential for generating cost savings within healthcare organizations while improving patient outcomes and experiences. By optimizing care delivery processes, leveraging health information technology, and promoting interdisciplinary collaboration, healthcare providers can achieve efficiencies across the care continuum and realize tangible financial benefits. Moreover, by embracing consumer-centric approaches, empowering patients, and leveraging evidence-based models, healthcare organizations can foster a culture of innovation, responsiveness, and continuous improvement. As healthcare continues to evolve, care coordination will remain a cornerstone strategy for achieving cost-effective, high-quality care that meets the needs of diverse patient populations.

References

Breckenridge, E. D., Kite, B., Wells, R., & Sunbury, T. M. (2019). Effect of patient care coordination on hospital encounters and related costs. Population Health Management, 22(5), 406–414. https://doi.org/10.1089/pop.2018.0176

Hannigan, B., Simpson, A., Coffey, M., Barlow, S., & Jones, A. (2018). Care coordination as imagined, care coordination as done: Findings from a cross-national mental health systems study. International Journal of Integrated Care, 18(3). https://doi.org/10.5334/ijic.3978

Karam, M., Chouinard, M.-C., Poitras, M.-E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, C. (2021). Nursing care coordination for patients with complex needs in primary healthcare: A scoping review. International Journal of Integrated Care, 21(1). https://doi.org/10.5334/ijic.5518

Khullar, D., & Chokshi, D. A. (2018). Can better care coordination lower healthcare costs? JAMA Network Open, 1(7), e184295. https://doi.org/10.1001/jamanetworkopen.2018.4295

Rocks, S., Berntson, D., Gil-Salmerón, A., Kadu, M., Ehrenberg, N., Stein, V., & Tsiachristas, A. (2020). Cost and effects of integrated care: A systematic literature review and meta-analysis. The European Journal of Health Economics, 21(8), 1211–1221. https://doi.org/10.1007/s10198-020-01217-5

Rodziewicz, T. L., & Hipskind, J. E. (2022). Medical error prevention. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/29763131/

Taylor, K. (2019). Embracing and advancing the consumerist era in healthcare. Frontiers of Health Services Management, 36(2), 15–25. https://doi.org/10.1097/hap.0000000000000069

Wilt, T., Duan-Porter, W., Miake-Lye, I., Diem, S., Ullman, K., & Majeski, B. (2020). Department of Veterans Affairs Veterans Health Administration Health Services Research & Development Service. https://www.hsrd.research.va.gov/publications/esp/care-coordination-models.pdf

Detailed Assessment Instructions for the NURS FPX 6612 Cost Savings Analysis Paper Assignment

Description

Assessment 4 Instructions: Cost Savings Analysis Paper Assignment

Cost Savings Analysis

Overview

  • Prepare a spreadsheet of cost savings data showing efficiency gains attributable to care coordination over the course of one fiscal year, and report your key findings in an executive summary, 4–5 pages in length.
  • Information plays a fundamental role in health care. Providers such as physicians and hospitals create and process information as they deliver care to patients. However, managing that information and using it productively poses an ongoing challenge, particularly in light of the complexity of the U.S. health care sector, with its many diverse settings for care and types of providers and services. Health information technology (HIT) has the potential to considerably increase the productivity of the health sector by assisting providers in managing information. Furthermore, HIT can improve the quality of health care and, ultimately, the outcomes of that care for patients.
  • The use of HIT has been upheld as having remarkable promise in improving the efficiency, quality, cost-effectiveness, and safety of medical care delivery in our nation’s health care system. This assessment provides an opportunity for you to examine how utilizing HIT can positively affect the financial health of an organization, improve patient health, and create better health outcomes.
  • 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. 
      • Describe ways in which care coordination can generate cost savings.
    • Competency 2: Explain the relationship between care coordination and evidence-based data. 
      • Describe ways in which care coordination efforts can enhance the collection of evidence-based data and improve quality through the application of an emerging health care model.
    • Competency 3: Use health information technology to guide care coordination and organizational practice. 
      • Explain how care coordination can promote improved health consumerism and effect positive health outcomes.
    • Competency 4: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards. 
      • Present cost savings data and information clearly and accurately.
      • Support main points, claims, and conclusions with relevant and 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.

    • 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:
    • What is the main focus of information gathering in health care?
    • How can care coordination efforts enhance the collection of evidence-based data and improve quality?
    • What governmental entities are leading care coordination practices?
    • What influence does data analysis have on the development and advancement of health care policy?
  • Assessment Instructions

Preparation
As the senior care coordinator in your organization, your manager has asked you to examine and report on how care coordination can generate cost savings, improve outcomes, enhance the collection of evidence-based data, and improve health care quality for the community. She would like you to compile cost savings data in a well-organized spreadsheet and present your key findings in an executive summary.

Note:

Remember that you can submit all or a portion of your draft spreadsheet and executive summary 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
Determine how care coordination can reduce costs. Compile your cost savings data in a spreadsheet, using Microsoft Excel or a suitable application of your choice. (If you elect to use an application other than Excel, check with faculty to avoid potential file compatibility issues.) Your spreadsheet should containat least fourcost-saving elements. Identify the cost-saving element, current costs, and anticipated savings.
Then create an executive summary using the APA Style Paper Template [DOCX]. Discuss your cost-saving elements and report key findings from your analysis.

Analyzing Cost Savings

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 Cost Savings Analysis Scoring Guide to better understand how each criterion will be assessed.

    • Describe ways in which care coordination can generate cost savings.
      • What are your primary evidence-based sources of information?
      • Are your conclusions substantiated by the data?
      • What assumptions, if any, underlie your analysis?
    • Explain how care coordination can promote improved health consumerism and effect positive health outcomes.
      • What evidence do you have to substantiate your claims?
    • Describe at least five ways in which care coordination efforts can enhance the collection of evidence-based data and improve quality through the application of an emerging health care model. 
      • Choose any emerging health care model.
    • Present cost savings data and information clearly and accurately.
    • Support main points, claims, and conclusions with relevant and credible evidence, correctly formatting citations and references using APA style.

Additional Requirements

    • Executive Summary Format and Length
      Format your executive summary 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 theAPA Style Paper Tutorial [DOCX]to help you in writing and formatting your executive summary.
    • Your summary should be 4–5 pages in length,not includingthe title page and references page.

Supporting Evidence

    • Cite 4–5 sources of relevant and credible scholarly or professional evidence to support your cost savings analysis.
    • Apply APA formatting to all in-text citations and references.
    • Submit both your spreadsheet and your executive summary.
      Portfolio Prompt: You may choose to save your spreadsheet and executive summary to your ePortfolio.

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NURS FPX 6612 Patient Discharge Care Planning Paper Example

NURS FPX 6612 Assessment 3 Patient Discharge Care PlanningNURS 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

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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  • Expert Writers: Let our skilled writers perfect your paper, providing the expertise needed for exceptional results.
  • Originality Guaranteed: Bid farewell to plagiarized papers. Our nursing experts craft original and customized nursing essays for your academic success.
  • Timely Support for Your Coursework: Worried about deadlines? We’ve mastered the art of helping nursing students with coursework, even with tight deadlines, saving your academic life.
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NURS FPX 6612 Quality Improvement Proposal Paper Example

NURS FPX 6612 Assessment 2 Quality Improvement ProposalNURS FPX 6612 Assessment 2 Quality Improvement Proposal

NURS FPX 6612 Quality Improvement Proposal Paper Assignment Brief

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

Assignment Title: NURS FPX 6612 Assessment 2 Quality Improvement Proposal

Understanding Assignment Objectives

This assignment aims to develop your skills in identifying healthcare quality improvement opportunities, conducting evidence-based research, and proposing feasible solutions to address identified issues. Through critical analysis and synthesis of relevant literature, you will demonstrate your ability to apply theoretical concepts to real-world healthcare settings and develop practical, evidence-based interventions to enhance patient outcomes and organizational performance.

The Student’s Role

As a student, your role is to act as a healthcare professional or administrator tasked with identifying and addressing a quality improvement opportunity within your organization or practice setting. You will conduct a thorough assessment of the identified problem, explore existing literature to support your proposed solution, and develop a comprehensive quality improvement proposal that addresses the identified issue and aligns with evidence-based practice principles.

Competencies Measured

This assignment assesses the following competencies:

  • Ability to identify healthcare quality improvement opportunities.
  • Skill in conducting evidence-based research and synthesizing findings.
  • Capacity to propose feasible and evidence-based solutions to healthcare challenges.
  • Proficiency in articulating expected outcomes and evaluating the effectiveness of proposed interventions.
  • Capability to communicate complex ideas and proposals effectively in a written format.

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 3 Patient Discharge Care Planning Example

NURS FPX 6612 Assessment 4 Cost Savings Analysis Example

NURS FPX 6612 Quality Improvement Proposal Paper Example

Introduction

In the pursuit of providing high-quality healthcare services while managing costs effectively, healthcare organizations increasingly turn to innovative solutions. One such solution is the implementation and expansion of Health Information Technology (HIT), which has shown promising results in improving patient outcomes and operational efficiency. This proposal aims to address the need for quality improvement within healthcare settings through the expansion of HIT infrastructure, guided by evidence-based practices and the principles of accountable care organizations (ACOs).

Overview of the Problem and Setting

Within the healthcare landscape, the challenge persists in delivering quality care while containing costs and ensuring patient safety. This issue is particularly pronounced in settings where patients present with complex health needs, requiring coordinated and comprehensive care. Unfortunately, the current landscape often grapples with insufficient information management systems and disjointed delivery of care, compounding these difficulties. Consequently, there arises an urgent call for interventions that not only streamline operational processes but also optimize the utilization of data, ultimately aiming to elevate the quality of care across the board.

Importance of Quality Improvement Initiative

A quality improvement initiative focusing on the expansion of Health Information Technology (HIT) infrastructure holds profound significance for numerous reasons. Firstly, it serves as a gateway to enhanced access to patient data, empowering healthcare providers with comprehensive information to guide their decision-making processes and customize interventions according to the unique needs of each individual (Alaei et al., 2019). Secondly, it fosters the seamless coordination of care and ensures continuity throughout the patient journey, thereby minimizing the occurrence of errors and eliminating unnecessary redundancies in treatment protocols (Barath et al., 2020). Lastly, through the strategic utilization of technology, healthcare organizations can achieve heightened levels of operational efficiency and cost-effectiveness, all while steadfastly upholding the highest standards of care delivery (Fraze et al., 2020).

Expected Outcome

The anticipated outcomes of implementing an expanded Health Information Technology (HIT) infrastructure are multifaceted and hold significant promise for improving healthcare delivery. Firstly, it is expected to lead to enhanced patient outcomes, characterized by reduced hospitalizations, more effective management of chronic conditions, and the implementation of advanced preventive care measures (Barath et al., 2020). By providing healthcare providers with comprehensive access to patient data and analytical tools, HIT facilitates more informed decision-making and personalized treatment plans, ultimately resulting in better health outcomes for patients.

Secondly, the expansion of HIT infrastructure aims to streamline administrative processes within healthcare organizations, thereby generating substantial time and cost savings for both patients and providers (Fraze et al., 2020). Through the automation of routine tasks, optimization of resource allocation, and reduction of paperwork, HIT enables more efficient operations and resource utilization. This, in turn, frees up valuable time for healthcare professionals to focus on delivering high-quality care and fosters a more seamless and patient-centered care experience.

Overall, the initiative seeks to transform healthcare delivery by harnessing the power of technology to optimize outcomes and experiences for all stakeholders (Alaei et al., 2019). By integrating HIT into various aspects of care delivery, healthcare organizations can achieve greater efficiency, effectiveness, and patient satisfaction. This transformative approach not only enhances the quality of care but also ensures that healthcare remains accessible, affordable, and sustainable in the long term.

Supporting Evidence from Previous Research

The body of research surrounding Health Information Technology (HIT) consistently highlights its efficacy in enhancing healthcare quality and outcomes. For example, a study by Fraze et al. (2020) elucidated the significant impact of HIT within accountable care organizations (ACOs), where the strategic utilization of care plans effectively addresses the multifaceted needs of patients, resulting in tangible improvements in health outcomes. By leveraging HIT tools to facilitate care coordination and personalized interventions, ACOs demonstrate superior performance in managing complex patient populations, ultimately leading to better overall outcomes.

Furthermore, research conducted by Barath et al. (2020) shed light on the compelling association between HIT implementation and reduced rates of preventable hospitalizations within ACO-affiliated healthcare settings. Through the seamless integration of HIT systems into clinical workflows, ACOs are better equipped to identify and address potential health issues proactively, thereby mitigating the need for unnecessary hospital admissions. These findings underscore the critical role of HIT solutions in driving meaningful improvements in care delivery by optimizing resource utilization and promoting proactive, patient-centered approaches to healthcare management.

By synthesizing evidence from these and other studies, it becomes evident that HIT holds immense potential for revolutionizing healthcare delivery by empowering providers with timely access to comprehensive patient data and analytical tools (Alaei et al., 2019). Through the strategic implementation of HIT solutions, healthcare organizations can capitalize on opportunities to enhance care coordination, improve clinical decision-making, and ultimately, optimize patient outcomes. As such, the integration of HIT into healthcare practice emerges as a pivotal strategy for driving continuous quality improvement and advancing the delivery of patient-centered care.

Steps for Implementation

The successful implementation of an expanded Health Information Technology (HIT) infrastructure demands meticulous planning and execution to ensure its effectiveness and seamless integration into healthcare workflows. A structured approach encompassing several key steps is essential to navigate the complexities associated with HIT deployment and maximize its potential benefits.

First and foremost, healthcare organizations must undertake a comprehensive assessment of their current technological capabilities to gauge existing infrastructure, software systems, and data management protocols (Gardner et al., 2018). This evaluation serves as a foundational step in identifying areas for enhancement and determining the specific HIT solutions that align with organizational goals and objectives.

Following the assessment phase, the next critical step involves identifying and securing the necessary resources and support required for HIT implementation. This includes allocating adequate financial resources, procuring technological infrastructure and software licenses, and engaging key stakeholders such as executive leadership, IT personnel, and frontline healthcare staff (Robert, 2019). Establishing clear lines of communication and fostering collaboration among multidisciplinary teams are essential to garnering buy-in and ensuring a smooth transition throughout the implementation process.

Moreover, the design of user-friendly interfaces and intuitive workflows is paramount to facilitate seamless adoption and utilization of HIT systems by healthcare providers (Fraze et al., 2020). Customized interfaces tailored to the specific needs and preferences of end-users can enhance usability, minimize training requirements, and promote efficient navigation within HIT platforms. Human-centered design principles should inform interface design, prioritizing simplicity, clarity, and accessibility to accommodate diverse user populations.

In parallel, comprehensive training programs must be developed and implemented to equip healthcare staff with the necessary skills and competencies to effectively utilize HIT tools in their daily practice (Gardner et al., 2018). Training sessions should be tailored to the roles and responsibilities of different staff members, covering topics such as system navigation, data entry protocols, and troubleshooting procedures. Ongoing support and refresher training sessions should also be provided to ensure sustained proficiency and confidence among users.

Finally, robust data security measures must be implemented to safeguard patient information and comply with regulatory requirements governing healthcare data privacy and security (Alaei et al., 2019). This entails implementing encryption protocols, access controls, audit trails, and regular security audits to mitigate the risk of data breaches and unauthorized access. Additionally, organizational policies and procedures should be established to govern data sharing practices and ensure compliance with relevant legal and ethical standards.

Evaluation Plan

To assess the effectiveness of the quality improvement initiative centered around the expansion of Health Information Technology (HIT) infrastructure, a comprehensive evaluation plan must be implemented. This plan encompasses the utilization of various metrics and indicators to gauge the impact of HIT expansion on healthcare delivery and patient outcomes.

One key aspect of the evaluation involves the examination of patient satisfaction scores, which serve as a crucial indicator of the overall patient experience and perceived quality of care (Barath et al., 2020). By soliciting feedback from patients through surveys or interviews, healthcare organizations can gain valuable insights into areas of strength and areas for improvement in their HIT-enabled care delivery processes.

Furthermore, evaluating the rates of preventable hospitalizations provides a quantitative measure of the effectiveness of HIT in improving care coordination and reducing unnecessary healthcare utilization (Fraze et al., 2020). A decrease in preventable hospitalizations suggests that HIT expansion has contributed to better management of chronic conditions, enhanced preventive care measures, and overall improvements in patient health outcomes.

Adherence to clinical guidelines serves as another essential metric for evaluating the impact of HIT expansion on care quality and patient safety (Robert, 2019). By tracking healthcare providers’ compliance with evidence-based practices and treatment protocols embedded within HIT systems, organizations can ensure consistency and standardization in care delivery, ultimately leading to better clinical outcomes.

Moreover, efficiency metrics related to resource utilization provide valuable insights into the cost-effectiveness of HIT-enabled care delivery models (Alaei et al., 2019). By analyzing factors such as patient flow, length of stay, and utilization of healthcare resources, organizations can identify opportunities for optimization and resource allocation, thereby improving operational efficiency and reducing healthcare costs.

In addition to quantitative metrics, qualitative feedback from healthcare providers and patients offers valuable insights into the perceived impact of HIT expansion on care delivery processes and outcomes (Gardner et al., 2018). Through interviews, focus groups, or open-ended surveys, organizations can capture firsthand perspectives on the usability, effectiveness, and overall value of HIT-enabled interventions, informing ongoing improvement efforts and enhancing the user experience.

By integrating both quantitative and qualitative evaluation methods, healthcare organizations can gain a comprehensive understanding of the impact of HIT expansion on care delivery and patient outcomes. This iterative approach to evaluation enables organizations to identify successes, address challenges, and continuously improve HIT-enabled care delivery models to ensure the highest standards of quality and patient-centered care.

Variables, Hypothesis, and Statistical Tests

To gauge the success of the quality improvement initiative centered around the expansion of Health Information Technology (HIT) infrastructure, various variables must be considered, each offering unique insights into the initiative’s impact on healthcare delivery and outcomes. Firstly, the adoption rate of HIT tools among healthcare providers serves as a critical variable, indicating the extent to which these technological solutions are integrated into clinical workflows and embraced by frontline staff (Fraze et al., 2020). A higher adoption rate suggests greater acceptance and utilization of HIT systems, potentially leading to more significant improvements in care quality and efficiency.

Secondly, changes in clinical outcomes represent another essential variable for assessment, encompassing factors such as patient health outcomes, disease management, and adherence to clinical guidelines (Barath et al., 2020). By tracking indicators such as hospital readmission rates, patient mortality rates, and disease-specific clinical metrics, organizations can ascertain whether the expansion of HIT infrastructure has resulted in tangible improvements in patient care and overall health outcomes.

Additionally, the realization of cost savings represents a key variable for evaluation, reflecting the financial impact of HIT expansion on healthcare organizations and the broader healthcare system (Robert, 2019). Cost savings may manifest in various forms, including reductions in healthcare expenditures, operational costs, and resource utilization. By quantifying these cost savings, organizations can demonstrate the economic value and return on investment associated with HIT-enabled care delivery models.

The underlying hypothesis guiding the evaluation posits that the expansion of HIT infrastructure will lead to improvements in care quality and efficiency (Alaei et al., 2019). This hypothesis is grounded in the premise that HIT solutions, by facilitating better access to patient data, streamlining care processes, and promoting evidence-based practices, have the potential to optimize care delivery and enhance patient outcomes.

To test this hypothesis and assess the significance of observed changes, statistical tests such as t-tests or chi-square analyses can be employed to analyze pre- and post-intervention data (Gardner et al., 2018). These tests enable organizations to determine whether any observed differences in variables such as adoption rates, clinical outcomes, and cost savings are statistically significant and not merely attributable to chance. By applying rigorous statistical analyses, organizations can confidently ascertain the effectiveness of HIT expansion initiatives and make data-driven decisions to inform future quality improvement efforts.

Conclusion

In conclusion, the expansion of Health Information Technology represents a promising avenue for enhancing healthcare quality and patient outcomes. By leveraging evidence-based practices and drawing on the principles of accountable care organizations, healthcare organizations can implement HIT solutions that drive meaningful improvements in care delivery. Through careful planning, implementation, and evaluation, the proposed quality improvement initiative holds the potential to revolutionize healthcare delivery and improve outcomes for patients.

References

Alaei, S., Valinejadi, A., Deimazar, G., Zarein, S., Abbasy, Z., & Alirezaei, F. (2019). Use of health information technology in patients care management: A mixed methods study in Iran. Acta Informatica Medica, 27(5), 311. https://doi.org/10.5455/aim.2019.27.311-317

Barath, D., Amaize, A., & Chen, J. (2020). Accountable care organizations and preventable hospitalizations among patients with depression. American Journal of Preventive Medicine, 59(1), e1–e10. https://doi.org/10.1016/j.amepre.2020.01.028

Fraze, T. K., Beidler, L. B., Briggs, A. D. M., & Colla, C. H. (2020). Translating evidence into practice: ACOs’ use of care plans for patients with complex health needs. Journal of General Internal Medicine, 36(1), 147–153. https://doi.org/10.1007/s11606-020-06122-4

Gardner, R. L., Cooper, E., Haskell, J., Harris, D. A., Poplau, S., Kroth, P. J., & Linzer, M. (2018). Physician stress and burnout: The impact of health information technology. Journal of the American Medical Informatics Association, 26(2), 106–114. https://doi.org/10.1093/jamia/ocy145

Moy, H., Giardino, A., & Varacallo, M. (2020). Accountable Care Organization. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448136/

Robert, N. (2019). How Artificial Intelligence is changing nursing. Nursing Management (Springhouse), 50(9), 30–39. https://doi.org/10.1097/01.numa.0000578988.56622.21

Detailed Assessment Instructions for the NURS FPX 6612 Quality Improvement Proposal Paper Assignment

Description

Assessment 1 Instructions: Quality Improvement Proposal Paper Assignment

Details:

Identify a quality improvement opportunity in your organization or practice. In a 1,250-1,500 word paper, describe the problem or issue and propose a quality improvement initiative based on evidence-based practice. Apply “The Road to Evidence-Based Practice” process, illustrated in Chapter 4 of your textbook, to create your proposal.

Include the following:

  1. Provide an overview the problem and the setting in which the problem or issue occurs.
  2. Explain why a quality improvement initiative is needed in this area and the expected outcome.
  3. Discuss how the results of previous research demonstrate support for the quality improvement initiative and its projected outcomes. Include a minimum of three peer-reviewed sources published within the last 5 years, not included in the course materials or textbook, that establish evidence in support of the quality improvement proposed.
  4. Discuss steps necessary to implement the quality improvement initiative. Provide evidence and rationale to support your answer.
  5. Explain how the quality improvement initiative will be evaluated to determine whether there was improvement.
  6. Support your explanation by identifying the variables, hypothesis test, and statistical test that you would need to prove that the quality improvement initiative succeeded.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, , which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. 

You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance.

Rubric:

Overview of the problem and the setting in which the problem or issue occurs is described in detail.

Explanation of why the quality improvement initiative is need is clearly discussed.

The quality improvement initiative would help address the problem within the described setting presented.

The expected outcome is thoroughly described.

Overall, the explanation is clear and well supported.

The use of research to demonstrate support for the quality improvement initiative and its projected outcomes is clearly presented.

The research results strongly demonstrate support for the initiative and projected outcomes.

The three peer-reviewed sources meet all assignment criteria and provide critical support for the initiative.

The steps necessary to implement the quality improvement initiative are thoroughly discussed.

The implantation steps are well supported with evidence and rationale.

An explanation for how the quality improvement initiative will be measured is presented in detail.

The evaluation is appropriate to the quality improvement initiative.

Evaluation proposed is well supported.

The variables, hypothesis, and statistical tests needed to prove the quality improvement succeeded are presented and accurate.

The proposed elements will prove whether the quality improvement succeeded.

Thesis is comprehensive and contains the essence of the paper.

Thesis statement makes the purpose of the paper clear. Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner.

All sources are authoritative.

Writer is clearly in command of standard, written, academic English.

All format elements are correct.

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NURS FPX 6612 Triple Aim Outcome Measures Presentation Example

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures PresentationNURS 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 Case Presentation of a Patient Paper Example

NURS FPX 6610 Assessment 4 Case PresentationNURS FPX 6610 Assessment 4 Case Presentation

NURS FPX 6610 Case Presentation of a Patient Paper Assignment Brief

Course: NURS-FPX6610 Introduction to Care Coordination

Assignment Title: NURS FPX 6610 Assessment 4 Case Presentation

Assignment Overview

In this assessment, you will develop a presentation of a patient’s case for stakeholders, supplemented by 10–15 slides with notes. The ability to deliver effective presentations is crucial for care coordinators, particularly when addressing diverse groups of stakeholders, including patients, family members, and multiple providers in various settings. This assessment provides an opportunity for you to present a patient’s case to stakeholders, demonstrating your proficiency in key course competencies.

Understanding Assignment Objectives

This assignment aims to evaluate your ability to:

  • Explain the effect of societal, economic, and interprofessional factors on patient outcomes and the care coordinator’s role.
  • Evaluate care coordination plans and outcomes according to performance measures and professional standards.
  • Develop collaborative interventions that address the needs of diverse populations and varied settings.
  • Communicate effectively with diverse audiences, presenting patient case information to stakeholders clearly and accurately, and supporting main points with relevant evidence.

The Student’s Role

As a student in this assignment, your role is to prepare and deliver a comprehensive presentation of a patient’s case to stakeholders. You will analyze the patient’s background, care plan, and transitional care plan, identifying key goals, elements, and factors influencing outcomes. Additionally, you will explain how an interprofessional care team contributes to high-quality patient outcomes and determine the resources needed for continuing care.

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 3 Transitional Care Plan Example

NURS FPX 6610 Case Presentation of a Patient Paper Example

Slide 1: Title Slide

Title: Comprehensive Case Presentation for Mrs. Snyder’s Continuing Care

Course Code: NURS FPX 6610

Presenter’s Name: [Student’s Name]

Date: [Date of Presentation]

Speaker Notes:

  • Good morning/afternoon, everyone. Today, I’m excited to present a comprehensive case study focusing on Mrs. Snyder’s continuing care.
  • We’ll look at the details of transitional care, stakeholder engagement, and the multidisciplinary approach to ensure optimal patient outcomes for Mrs. Snyder.
  • Let’s dive into the details of Mrs. Snyder’s case and explore the collaborative efforts of healthcare professionals in providing patient-centered care.

Slide 2: Introduction

Importance of Case Studies in Healthcare

  • Case studies play a crucial role in providing insights into patient care (Hinchliffe et al., 2020).
  • They offer comprehensive patient information, aiding healthcare providers in understanding diagnoses, treatment options, and potential health issues.

Speaker Notes:

  • Case studies serve as invaluable tools for healthcare professionals, offering a detailed overview of patient cases.
  • In today’s presentation, we’ll explore how case studies, particularly Mrs. Snyder’s, contribute to our understanding of transitional care and collaborative patient management.

Slide 3: Transitional Care Plan and Goals

Definition of Transitional Care

  • Transitional care focuses on ensuring the smooth transition of patients between healthcare settings (Daliri et al., 2019).
  • Its primary goal is to uphold the quality of care while respecting patients’ preferences and needs during transitions.

Goals of Continuing Care for Mrs. Snyder

  • Ensure seamless transfer between healthcare settings.
  • Uphold the quality of care and treatment.
  • Respect religious and cultural beliefs, particularly in Mrs. Snyder’s case (Lianov et al., 2020).

Speaker Notes:

  • Transitional care is essential for patients like Mrs. Snyder who require transfer between medical centers.
  • The goal is to facilitate a stress-free transition for Mrs. Snyder while maintaining the quality of care and respecting her religious and cultural preferences.

Slide 4: Stakeholder Engagement

Role of Stakeholders in Patient Health and Safety

  • Stakeholders play a crucial role in shaping patient care and well-being (Lianov et al., 2020).
  • Their involvement ensures that patients receive optimal care and support throughout their healthcare journey.

Importance of Stakeholder Collaboration in Mrs. Snyder’s Case

  • Collaborative efforts are essential in ensuring a smooth transfer process for Mrs. Snyder.
  • Healthcare professionals must prioritize her needs and preferences, including cultural considerations like providing kosher food (Lianov et al., 2020).

Speaker Notes:

  • Stakeholders, including healthcare professionals and family members, play a pivotal role in Mrs. Snyder’s care.
  • Collaboration ensures that Mrs. Snyder’s transfer is seamless and that her cultural and religious beliefs are respected throughout the process.

Slide 5: Elements of Continuous Care

Components of Continuous Care

  • Medical record analysis: Understanding Mrs. Snyder’s medical history and current health status (Asmirajanti et al., 2019).
  • Patient evaluation: Assessing Mrs. Snyder’s physical, emotional, and cultural needs.
  • Emotional support: Providing Mrs. Snyder with the necessary support to navigate her healthcare journey effectively.

Importance of Understanding Mrs. Snyder’s Medical History

  • Mrs. Snyder’s medical history, including her battle with ovarian cancer and diabetes, informs her ongoing treatment and care plan (Khanlarkhani et al., 2021).

Speaker Notes:

  • Continuous care involves a comprehensive approach to Mrs. Snyder’s health and well-being.
  • Understanding her medical history and current health status is crucial for tailoring effective treatment plans and ensuring optimal outcomes.

Slide 6: Mrs. Snyder’s Health Assessment

Overview of Mrs. Snyder’s Health Issues

  • Mrs. Snyder faces multiple health challenges, including ovarian cancer, diabetes, and stress-related issues (Khanlarkhani et al., 2021; Demir et al., 2021).
  • These conditions significantly impact her overall well-being and require specialized care and attention.

Impact on Mrs. Snyder’s Well-being

  • Mrs. Snyder’s health issues pose significant challenges, affecting her physical and emotional health (Khanlarkhani et al., 2021; Demir et al., 2021).
  • Understanding the extent of these challenges is essential for developing a comprehensive care plan tailored to her needs.

Speaker Notes:

  • Mrs. Snyder’s health assessment reveals the complexity of her medical condition.
  • Her health issues, including ovarian cancer and diabetes, require a holistic approach to address both physical and emotional well-being.

Slide 7: Interprofessional Care Team

Composition of Mrs. Snyder’s Care Team

  • Mrs. Snyder’s care team comprises various specialists, including oncologists, endocrinologists, and nurses (Ansa et al., 2020).
  • Each team member plays a unique role in managing her complex health issues and ensuring coordinated care.

Speaker Notes:

  • Mrs. Snyder’s care team consists of a diverse group of healthcare professionals, each bringing their expertise to her treatment.
  • Collaboration among team members is essential for ensuring comprehensive care and optimal patient outcomes.

Slide 8: Factors Affecting Patient Outcomes

Determinants of Patient Outcomes

  • Patient outcomes can be influenced by various factors, including economic status, lifestyle choices, and social support systems (Chung et al., 2020).
  • Understanding these determinants is crucial for developing a tailored care plan that addresses Mrs. Snyder’s unique circumstances.

Speaker Notes:

  • Several factors, including economic status and social support, can impact patient outcomes.
  • Recognizing these determinants allows us to develop a care plan that addresses Mrs. Snyder’s individual needs and challenges.

Slide 9: Assumptions and Areas of Uncertainty

Acknowledging Assumptions in Mrs. Snyder’s Case

  • Cultural and religious considerations: Assumptions about Mrs. Snyder’s dietary preferences and religious beliefs must be taken into account.
  • Family dynamics: Understanding Mrs. Snyder’s family situation and support network is essential for providing comprehensive care.

Addressing Areas of Uncertainty

  • Uncertainties may arise throughout Mrs. Snyder’s care journey, requiring flexibility and adaptability from healthcare providers.
  • Ongoing training and communication among the care team are essential for addressing uncertainties effectively.

Speaker Notes:

  • Assumptions about Mrs. Snyder’s cultural and religious preferences guide our approach to her care.
  • However, uncertainties may arise, necessitating ongoing communication and flexibility among the care team.

Slide 10: Determination of Required Resources

Essential Resources for Mrs. Snyder’s Care

  • Monitoring vital signs: Regular assessment of Mrs. Snyder’s health indicators, including blood pressure and blood sugar levels (Howell et al., 2020).
  • Dietary modifications: Providing Mrs. Snyder with appropriate dietary options, including kosher food, to meet her cultural and religious needs (Lianov et al., 2020).

Speaker Notes:

  • Adequate resources, including monitoring equipment and dietary options, are essential for Mrs. Snyder’s care.
  • Ensuring access to these resources is crucial for maintaining her health and well-being throughout her healthcare journey.

Slide 11: Conclusion

Key Takeaways

  • Comprehensive transitional care is essential for patients like Mrs. Snyder, who require transfer between healthcare settings.
  • Interprofessional collaboration and patient-centered care are vital for ensuring optimal outcomes and addressing patients’ individual needs.

Speaker Notes:

  • Mrs. Snyder’s case highlights the importance of collaborative, patient-centered care in achieving optimal outcomes.
  • By prioritizing her needs and preferences, we can ensure that Mrs. Snyder receives the support and resources necessary for a smooth transition and recovery journey.

Slide 12: References

Ansa, B. E., Zechariah, S., Gates, A. M., Johnson, S. W., Heboyan, V., & De Leo, G. (2020). Attitudes and behavior towards interprofessional collaboration among healthcare professionals in a large academic medical center. Healthcare, 8(3), 323. https://doi.org/10.3390/healthcare8030323

Asmirajanti, M., Hamid, A. Y. S., & Hariyati, Rr. T. S. (2019). Nursing Care Activities Based on Documentation. BMC Nursing, 18(1). https://doi.org/10.1186/s12912-019-0352-0

Chung, G. K.-K., Dong, D., Wong, S. Y.-S., Wong, H., & Chung, R. Y.-N. (2020). Perceived poverty and health, and their roles in the poverty-health vicious cycle: A qualitative study of major stakeholders in the healthcare setting in Hong Kong. International Journal for Equity in Health, 19(1). https://doi.org/10.1186/s12939-020-1127-7

Daliri, S., Hugtenburg, J. G., ter Riet, G., van den Bemt, B. J. F., Buurman, B. M., Scholte op Reimer, W. J. M., van Buul-Gast, M.-C., & Karapinar-Çarkit, F. (2019). The effect of a pharmacy-led transitional care program on medication-related problems post-discharge A before—After prospective study. Plos One, 14(3), 0213593. https://doi.org/10.1371/journal.pone.0213593

Demir, S., Nawroth, P. P., Herzig, S., & Ekim Üstünel, B. (2021). Emerging targets in type 2 diabetes and diabetic complications. Advanced Science, 8(18), 2100275. https://doi.org/10.1002/advs.202100275

Hinchliffe, R. J., Forsythe, R. O., Apelqvist, J., Boyko, E. J., Fitridge, R., Hong, J. P., Katsanos, K., Mills, J. L., Nikol, S., Reekers, J., Venermo, M., Zierler, R. E., & Schaper, N. C. (2020). Guidelines on diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update). Diabetes/Metabolism Research and Reviews, 36(1). https://doi.org/10.1002/dmrr.3276

Slide 13: Q&A

  • Inviting Questions from Stakeholders

Speaker Notes:

  • Thank you for your attention. I’m happy to address any questions or concerns you may have about Mrs. Snyder’s case or our approach to her care.
  • Please feel free to ask any questions, and I’ll do my best to provide comprehensive answers based on the information presented today.

Detailed Assessment Instructions for the NURS FPX 6610 Case Presentation of a Patient Paper Assignment

Description

Assessment 3 Instructions: Case Presentation of a Patient Paper

  • Develop a presentation of the patient’s case for stakeholders, supplemented by 10–15 slides with notes.
    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.
  • The ability of care coordinators to deliver effective presentations can have a significant impact on the quality of patient care, particularly when addressing a diverse group of stakeholders, including the patient, family members, and multiple providers in a range of different settings. This assessment provides an opportunity for you to present Mrs. Snyder’s case to stakeholders.
    Communication and interdisciplinary collaboration include the patients and their families or significant others. Care coordinators understand that patients may need help navigating the complex health care system and that partnering with patients and their families improves education, safety, and patient outcomes.
    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.
      • Identify the factors that could affect outcomes for a patient.
    • Competency 3: Evaluate care coordination plans and outcomes according to performance measures and professional standards.
      • Determine the resources needed to implement continuing care.
    • Competency 4: Develop collaborative interventions that address the needs of diverse populations and varied settings.
      • Identify the goals, elements, and overall scope of a plan for continuing care.
      • Explain how an interprofessional care team delivers high-quality patient outcomes.
    • Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
      • Present patient case information to stakeholders clearly and accurately.
      • Support main points, arguments, and conclusions with relevant and 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
    For your final assessment, you will present Mrs. Snyder’s case to the health care team, including all internal and external stakeholders and key family members. The purpose of the presentation is to ensure that everyone connected with Mrs. Snyder’s case is well informed and that they have a common understanding of her care to date and of plans for providing the best possible patient-centered care.
    To prepare for the presentation, you are encouraged to review the care plan and the transitional care plan that you developed for Mrs. Snyder in Assessments 2 and 3.
    Note: Remember that you can submit all or a portion of your presentation draft to Smarthinking for feedback before you submit the final version for 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. Use the speaker’s notes section of each slide to develop your talking points and cite your sources, as appropriate. If you need help designing your presentation, you are encouraged to review the various presentation resources provided.
    Inclusion of audio voiceover or video is optional. Required information should be included in the slides and speaker notes.
    You may use Kaltura or another technology of your choice to record your presentation. If using Kaltura, refer to the Using Kaltura page for directions on recording and uploading your video in the courseroom.
    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 4 Example [PPTX].
    • Requirements
      Develop a presentation of your patient’s case for stakeholders.
      Presentation Format and Length
      Your slide deck should consist of 10–15 slides, not including the title slide, objectives slide, and references slide.
      Supporting Evidence
    • Cite 3–5 sources of scholarly or professional evidence to support your presentation.
    • List your sources on the references slide at the end of your presentation.
    • Developing the Presentation
      The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your case presentation addresses each point, at a minimum. Read the Case Presentation Scoring Guide to better understand how each criterion will be assessed.
    • Identify the goals, elements, and overall scope of a plan for continuing care.
      • Include a high-level overview of the care plan and the transitional care plan, with relevant background on the patient.
    • Explain how an interprofessional care team delivers high-quality patient outcomes.
      • Include and address the various roles associated with particular care coordination functions.
      • Cite credible evidence to support your conclusions.
      • Consider the informational needs of various stakeholders and their familiarity with care coordination.
    • Identify the factors that could affect outcomes for a patient.
      • Specify the information on which are you basing your conclusions.
      • Note any assumptions you are making about the specific patient, her needs, and the nature of ongoing care.
    • Determine the resources needed to implement continuing care.
      • Identify the factors that influence your determination.
      • Justify your assertions, specific to Mrs. Snyder’s case.
    • Present patient case information to stakeholders clearly and accurately.
      • Express your main points and conclusions coherently.
      • Proofread your slides to minimize errors that could distract readers and make it difficult to focus on the substance of your presentation.
    • Support main points, arguments, and conclusions with relevant and credible evidence, correctly formatting citations and references using APA style.
      • Ensure that the evidence you provide is clear, explicit, and understood by all stakeholders.
    • Additional Requirements
      Submit your slide deck and, if you included audio voiceover or video, a link to your recording. If you used technology other than PowerPoint or Kaltura to create your slides or recording, make sure to submit any other relevant documentation or links for this assessment.
      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 PlanNURS 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.

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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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