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

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

Assignment Brief: NURS FPX 6616 Summary Report on Rural Health Care and Affordable Solutions

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

Assignment Title: NURS FPX 6616 Assessment 2 Summary Report on Rural Health Care and Affordable Solutions

Assignment Overview

In this assignment, you will develop a 4-5 page summary report addressing rural health care challenges and proposing potential solutions. You will focus on understanding the needs of a specific rural community and a particular patient population within it, identifying interprofessional team providers, analyzing cultural competency requirements, recommending technology-based outreach strategies, identifying legal issues, and explaining the continuation of ethical care in the updated system.

Understanding Assignment Objectives

This assignment aims to evaluate your ability to analyze ethics and legal implications in care coordination, critically appraise collaborative relationships with care coordination stakeholders, recommend care coordination standards, determine components of effective culturally competent care coordination environments, and communicate effectively with diverse audiences.

The Student’s Role

As a care coordination consultant in a rural area, your role is to identify affordable solutions to complex patient issues. You will design a care coordination plan focusing on one specific patient population, considering cultural diversity and legal and ethical considerations.

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

NURS FPX 6616 Assessment 1 Community Resources and Best Practices Example

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

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

Introduction

Despite financial constraints, residents of rural regions should have access to high-quality medical treatment within their means. Roughly 25 percent of the United States’ total population, or 61 million people, reside in rural regions (Anderson & Singh, 2021). Compared to metropolitan regions, rural areas suffer from fewer people being aware of and educated about health issues, fewer people having access to reliable transportation, more people living in poverty, a larger proportion of the elderly, and fewer people having access to adequate health care. The prevalence of diabetes in the United States is greater in rural regions by 16%. Diagnosis rates for cancer patients in the United States are significantly lower than in other developed countries. Their colon cancer mortality rate is 9-16% higher because they have a harder time getting to treatment centers (Anderson & Singh, 2021).

Case Scenario

Diabetes is a condition identified in Stella; a patient who is 45 years old. She went to the hospital for a physical examination around two weeks ago. She goes through a yearly checkup that is thorough. The electronic health record (EHR) and telehealth systems are experiencing technical difficulties. She cannot fall asleep because she cannot be drawn in any direction by anything. Because of these unfortunate events, she will be late for her arranged meeting. A few days later, she called the institution and found that her information had been erased from the hospital’s database due to a security breach. She obtained this information after calling the facility.

Strategic Approach

This paper aims to recognize a community and its requirements by acknowledging cultural competencies and legal challenges unique to Stella and then to offer technology-based outreach tactics to meet those needs. Now is the time to implement solutions that will remove obstacles to providing healthcare to people in rural areas. Telehealth, coupled with the right training and education to assure its efficacy and not breach their information, is the technique that will assist in delivering both economical and easily accessible care.

Population & Community Needs

This analysis will fous on the healthcare requirements of the United States population, with a specific focus on rural areas. Residents in these regions confront significant challenges accessing healthcare services and information, often resulting in delayed diagnoses of serious illnesses such as cancer and diabetes. Ensuring affordable and easily accessible healthcare services is paramount for these individuals. Introducing telehealth solutions can effectively address these needs by providing remote access to healthcare resources, thereby improving their overall quality of life and enabling better management of their health conditions. Moreover, telehealth initiatives have demonstrated cost-effectiveness, with potential savings of up to $34 per patient (Haleem et al., 2021).

Within rural healthcare settings, it is imperative for healthcare teams to be adequately equipped to serve the diverse demographics of their patient population. Effective communication becomes crucial, especially in navigating potential language barriers that may impede patients from articulating their healthcare needs effectively. Additionally, fostering cultural awareness among healthcare providers is essential, as it enables them to understand and respect the various religious and cultural backgrounds of their patients. Cultivating cultural competence within healthcare teams can help dismantle barriers to care, leading to enhanced patient safety, decreased healthcare expenditures, and improved efficiency in healthcare delivery (Gerchow et al., 2020).

Analyzing Current Interprofessional Team Providers & Resources

In rural healthcare delivery, fostering interprofessional collaboration is indispensable for ensuring comprehensive patient care. However, the advent of telehealth introduces complexities in preserving patient privacy and confidentiality. Healthcare practitioners are mandated to adhere to legal frameworks such as the Health Insurance Portability and Accountability Act (HIPAA) to protect patient information and uphold trust in the healthcare system. Effectively managing communication channels among team members while safeguarding patient privacy emerges as a critical component of efficient care coordination.

In the sphere of healthcare, safeguarding patient confidentiality transcends mere legal compliance; it serves as a cornerstone for cultivating trust between healthcare providers and patients (Keshta & Odeh, 2020). Protecting sensitive patient information is paramount for safeguarding patient safety and preserving the sanctity of the doctor-patient relationship. Breaches in patient confidentiality not only pose substantial risks to patient well-being but also erode the trust reposed in healthcare providers on a global scale. Addressing this challenge entails a collective commitment to upholding principles and guidelines that safeguard patients’ right to privacy during medical interventions. Legal instruments like the Data Protection Act play a pivotal role in establishing robust standards for the handling and security of private health information, thereby reinforcing the ethical foundation of confidentiality in healthcare (Keshta & Odeh, 2020).

While effective communication and collaboration among healthcare team members are paramount for delivering optimal care, it is imperative to ensure that sensitive patient information is shared judiciously, only with individuals directly involved in the patient’s care. Regrettably, instances of healthcare providers divulging patient details to unauthorized parties are not uncommon, whether stemming from negligence, carelessness, or malice. Such breaches undermine the trust essential to the doctor-patient relationship and may have detrimental effects on patient health outcomes. Diminished trust between patients and healthcare providers can result in hesitancy in seeking treatment and adhering to follow-up appointments, ultimately compromising the quality of care provided (Eastwood & Maitland-Scott, 2020).

Areas of Cultural Competency to be Addressed

In the context of healthcare, nurses play a crucial role in delivering culturally competent care, which necessitates a thorough understanding of diverse cultural backgrounds. It is imperative for nurses to receive education and training aimed at enhancing their cultural competence to effectively navigate language barriers and foster collaborative teamwork (Kaihlanen et al., 2019).

Cultural Competence

Cultivating cultural competence among nurses fosters a supportive environment that positively impacts patient care by promoting openness and respecting patients’ cultural perspectives. This approach acknowledges the moral and ethical implications of cultural sensitivity, emphasizing the importance of patient privacy and autonomy in aligning with their cultural beliefs. Nurses should possess comprehensive knowledge of various cultures, religions, and worldviews to deliver cutting-edge care that enhances patients’ quality of life and ensures effective management of their health conditions (Červený et al., 2022).

Healthcare providers must be equipped with the necessary cultural competence to facilitate patients’ access to appropriate care and support them in making positive lifestyle changes. Effective therapy hinges on maintaining confidentiality, tailoring interventions to individual needs, and demonstrating sensitivity to cultural norms and differences. Nursing instructors play a pivotal role in training nurses to approach patient care with respect for diverse cultural backgrounds and to overcome linguistic barriers to communication and collaboration effectively (Liu et al., 2022). Moreover, it is essential to consider environmental factors that may influence both patients and healthcare providers during the implementation of cultural competence initiatives.

Technology-Based Outreach Strategies

In modern healthcare, safeguarding patient health information (PHI) is paramount, especially within the framework of the Health Insurance Portability and Accountability Act (HIPAA). PHI, as defined by HIPAA, encompasses any electronically communicated or stored health information, extending beyond mere spoken exchanges to include electronic transmissions (Grispos et al., 2021). For instance, inadvertent disclosures in public spaces, such as discussing surgical procedures in crowded elevators, can constitute HIPAA violations. Key components of PHI within medical records include admissions criteria, billing history, patient information, prescription records, consultations, and appointments for discharge and aftercare. Compliance with HIPAA security and privacy standards is mandatory for all healthcare facilities to ensure the confidentiality and integrity of patient data (Grispos et al., 2021).

Ensuring the privacy and security of individual patient health records is crucial in the face of advancing information technologies. Historically, healthcare providers have utilized patient data for research while preserving anonymity. However, contemporary regulations prohibit the use of protected health information (PHI) that could identify patients or their associates, necessitating careful redaction (Tariq & Hackert, 2019).

Maintaining the Privacy and Integrity of Individual Patients’ Health Records

HIPAA legislation serves as a cornerstone for safeguarding patient privacy and security in healthcare settings. Comprising both the Privacy Rule and the Security Rule, HIPAA sets forth stringent guidelines for the use and protection of digitally stored health information (Edemekong & Haydel, 2019). The Privacy Rule specifically delineates categories of identifiers that constitute protected health information (PHI), encompassing data related to individuals’ health status and medical care provision or payment. HIPAA’s enactment aimed to address three primary aspects of patient care: ensuring portability of health insurance coverage, streamlining administrative operations through electronic record-keeping, and enhancing technological advancements while safeguarding against PHI breaches (Edemekong & Hayden, 2019).

Patient Health Information (PHI) encompasses various types of data transmitted or stored electronically, as stipulated by HIPAA regulations. This includes admissions criteria, billing history, patient demographics, prescription records, referrals, and appointments for discharge and follow-up care (Isola & Al Khalili, 2020). Compliance with HIPAA regulations is essential to uphold patient confidentiality and security across healthcare delivery settings.

Possible Legal Issues

The regulations outlined in the Health Insurance Portability and Accountability Act (HIPAA) are applicable to nearly all facets of hospital and medical facility operations. Protected health information (PHI) must be safeguarded both within the workplace and at home. Healthcare providers are obligated to disclose only the minimum necessary health information, such as HR or related services, when interacting with patients (Chuma & Ngoepe, 2021). For instance, pharmacists should ensure patients understand how to properly take prescribed medications before initiating any detailed discussions. HIPAA prohibits extensive conversations with patients in the presence of others.

Similarly, HIPAA regulations extend to communications between healthcare workers involved in patient care. While a radiologist may inquire about the necessity of a particular test with the ordering medical resident, such discussions must remain within the realm of patient care and not be shared with unrelated parties (Solimini et al., 2021). Prior consent from the patient is essential before disclosing any medical information to third parties, whether in text, audio, or video format.

Legal considerations are paramount in telehealth to safeguard patients from harm, particularly concerning data breaches and confidentiality. Collaboration between nurses and IT professionals is crucial to mitigate the risks of security breaches associated with telemedicine (Solimini et al., 2021). Non-compliance with telehealth policies may lead to criminal prosecution and other legal repercussions. Obtaining patient consent before recording or storing any patient data is essential, and efforts to increase public awareness and education on telemedicine ethics are imperative (Gajarawala & Pelkowski, 2020).

Continuation of Ethical Care in the System

Despite technological advancements, maintaining patient confidentiality remains a challenge in healthcare settings. While efforts are made to uphold confidentiality, breaches may sometimes be unavoidable but not necessarily unethical. Healthcare professionals understand the importance of confidentiality but may face challenges in preventing breaches. To address this, a preliminary ethical code of conduct for clinical settings has been proposed, outlining guidelines for maintaining confidentiality and circumstances where breaches may be acceptable. This draft encompasses factors such as patient privacy, management concerns, organizational ethics, and the doctor-patient relationship (Elhoseny et al., 2021).

In this context, it is crucial for all healthcare practitioners to safeguard patient information, whether it is stored in paper or digital records. Familiarity with the Health Insurance Portability and Accountability Act (HIPAA), enacted in 1996, is essential, as it establishes regulations for protecting patient information, including rules for record storage, inspection, and measures to prevent data misuse (CDC, 2018).

The concept of absolute confidentiality is challenged when concerns arise regarding the safety of a third party or public health. In modern medicine, sharing patient data without their consent should generally be avoided unless justified by normative standards. Exceptions to complete confidentiality without patient agreement include situations such as legally valid requests, actions in the patient’s best interest, safeguarding society’s welfare, and protecting third parties from serious harm or threats (Varkey, 2021).

Ensuring ethical care continuity in telehealth practices requires careful consideration of patient confidentiality and security. Nurses must be educated on compliance with various policies to maintain ethical standards in the system. Transparency and competent care delivery are essential, and no information should be disclosed online or to other professionals outside of work without proper consent. Identifying potential risk points in the system and collaborating with IT experts are vital steps in preventing breaches (Keenan et al., 2020).

Conclusion

In conclusion, addressing the healthcare needs of rural populations requires a multifaceted approach that encompasses technological innovation, legal compliance, cultural competence, and ethical considerations. Telehealth emerges as a promising solution to bridge the gap in healthcare access for rural residents, offering cost-effective and easily accessible care. However, ensuring the privacy and confidentiality of patient information remain paramount, necessitating adherence to legal frameworks like HIPAA and the implementation of robust security measures. Moreover, fostering cultural competence among healthcare providers is essential to deliver patient-centered care that respects diverse cultural backgrounds. The development of ethical guidelines and ongoing education can further support the continuity of ethical care in telehealth practices. By integrating these strategies, healthcare systems can enhance the quality and accessibility of healthcare services for rural populations while upholding ethical principles and legal standards.

References

Anderson, R., & Singh, D. (2021). Health needs assessment in rural America: The paradox of long-term care access. Journal of Rural Health, 37(2), 241-244.

CDC. (2018). Health Insurance Portability and Accountability Act (HIPAA). Centers for Disease Control and Prevention. https://www.cdc.gov/phlp/publications/topic/hipaa.html

Chuma, T. L., & Ngoepe, M. A. (2021). Understanding the Health Insurance Portability and Accountability Act (HIPAA): A legal perspective. Journal of Law, Medicine & Ethics, 49(1_suppl), 45-49.

Červený, M., et al. (2022). Cultural competence in nursing: A scoping review. Nursing Ethics, 29(1), 157-169.

Eastwood, K. A., & Maitland-Scott, C. (2020). Maintaining patient confidentiality in healthcare: A practical approach. Journal of Medical Ethics, 46(1), 45-49.

Edemekong, P. F., & Haydel, M. J. (2019). Health Insurance Portability and Accountability Act. In StatPearls [Internet]. StatPearls Publishing.

Elhoseny, M., et al. (2021). Ethical considerations in healthcare: A scoping review. Journal of Medical Ethics, 47(1), 33-37.

Gajarawala, S. N., & Pelkowski, J. N. (2020). Telehealth ethics: A scoping review. Journal of Bioethical Inquiry, 17(1), 21-29.

Gerchow, L., et al. (2020). Cultural competence in healthcare: A systematic review. Journal of Cultural Diversity, 27(2), 45-52.

Grispos, G., et al. (2021). Security and privacy in healthcare: A review. Journal of Biomedical Informatics, 113, 103655.

Haleem, A., et al. (2021). Telehealth: A scoping review of ethical considerations. Journal of Medical Ethics, 46(1), 45-49.

Isola, A., & Al Khalili, Y. (2020). Security and privacy of patient health information: A review. Journal of Cybersecurity, 4(1), 45-52.

Kaihlanen, A. M., et al. (2019). Cultural competence in nursing: A systematic review. Journal of Transcultural Nursing, 30(4), 395-404.

Keenan, K., et al. (2020). Ethical considerations in telehealth: A systematic review. Journal of Telemedicine and Telecare, 26(1-2), 13-22.

Keshta, I. A., & Odeh, M. (2020). Patient confidentiality in healthcare: A systematic review. Journal of Patient Safety & Quality Improvement, 8(2), 45-52.

Liu, Y., et al. (2022). Cultural competence in nursing education: A scoping review. Journal of Nursing Education, 61(1), 45-52.

Solimini, A. G., et al. (2021). Legal and ethical considerations in telehealth: A systematic review. Journal of Legal Medicine, 41(1-2), 45-52.

Tariq, J., & Hackert, B. (2019). Health data protection in healthcare: A review. Journal of Health Informatics, 25(1), 45-52.

Varkey, P., et al. (2021). Patient confidentiality in telehealth: A scoping review. Journal of Medical Internet Research, 23(1), 45-52.

Detailed Assessment Instructions for the NURS FPX 6616 Summary Report on Rural Health Care and Affordable Solutions Paper Assignment

Description

Assessment 2 Instructions: Summary Report on Rural Health Care and Affordable Solutions

Top of Form

Bottom of Form

Prepare a 4-5 page summary report of a rural health care problem and potential solutions.

Introduction

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

Turning barriers into bridges is a skill you will want to develop as a care coordination expert. Today, care coordination is required often in rural areas where there are limited resources and the need to work creatively with inter-professional team members who may reside outside of the local area. The use of telehealth becomes a bridge to care coordination as a collaborative tool for health care providers as a team of specialist.

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

Preparation

For this assessment, you will develop prepare summary report for improved rural health in the form of a scholarly document.

Review the Resources for this assessment and conduct your own library research to develop and support your ideas.

Note: Remember that you can submit all, or a portion of, your work 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.

As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.

As you think about rural areas and care coordination efforts, consider the importance of effectively utilizing interprofessional teams.

• What types of communication strategies would you, as a care coordination team leader of interprofessionals, consider to enhance collaborative understanding and respectful partnerships?
• How can you help the interprofessional team prepare to be a competent care delivery team of evidence-based care?

Implementing or changing the use of technology is ongoing in care coordination practice.

• What type of strategy would you consider to enhance collaborative efforts with interprofessional team members with technology?
• How does technology alter the care coordination efforts when used effectively?
• What types of issues do you need to keep at the forefront when using technology to enhance communication and care?

In each population or community, a care coordinator will have specific needs and challenges.

• What is most important when you consider cultural competence for the care coordination team within the context of legal and ethical care delivery?

Requirements

Prepare a 4–5 page summary report of a rural health care problem and potential solutions.

Summary Report Format

Use APA format. Create headings based on the scoring guide criteria. Your faculty may provide a template.

Supporting Evidence

Cite 5–7 sources of credible, scholarly, or professional evidence to support your claims and solutions.

Directions

There are many opportunities to turn barriers into bridges when working with limited resources. Imagine you are working as a care coordination consultant in a rural area and you need to find affordable solutions to many complex patient issues. You have decided to start with one type of patient population to design a path for care coordination using the resources in the community in conjunction with telehealth with regional outreach partners.

Following these instructions will help ensure you meet the scoring guide criteria:

• Identify and describe a rural community, the patient issues they face, and one specific population you can assist with this plan. Address any cultural or diversity-aware responsibilities the care coordinator should consider.
• Identify the interprofessional team providers currently available in the rural community. Analyze how they can be assisted by telehealth partners in the region, and any other stakeholders that may be involved.
• Describe the nuances for this population related to cultural competence for the interprofessional team, and how this affects care coordination and collaboration.
• Recommend technology-based outreach strategies supported by evidence-based research. Incorporate proven educational and evidence-based strategies, and how they might be modified using the outreach partners to enhance care in this rural community. Also, do consider the legal issues with telehealth and how this new strategy provides a clear path to ethical practice into the future.
• Support main points, claims, and conclusions with relevant and credible evidence, correctly formatting citations and references using APA style.

Scoring Guide Criteria

Your assessment should meet the following scoring guide criteria:

1. Describe a specific population need and the community.
2. Analyze current available interprofessional team providers and resources.
3. Identify areas of cultural competency the team must address.
4. Recommend technology-based outreach strategies supported by evidence-based research.
5. Identify possible legal issues.
6. Explain the continuation of ethical care in the updated system.
7. Communicate effectively in an appropriate form and style, consistent with applicable professional and scholarly standards.

Additional Requirements

• Your assessment should also meet the following requirements:
• Written communication: Written communication is free of errors that detract from the overall message.
• APA formatting: Your paper should demonstrate current APA style and formatting.
• Number of resources: Include 5–7 resources, appropriately cited throughout your paper and in your reference list.
• Length: 4–5 pages, typed and double-spaced, not including the title page and reference list.
• Font and font size: Times New Roman, 12 point.

Portfolio Prompt: You may choose to save this learning activity 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 the use of ethics to enhance coordinated care.

6. Explain the continuation of ethical care in the updated system.

. Competency 2: Evaluate the legal implications in care coordination.

7. Identify possible legal issues.

. Competency 3: Critically appraise collaborative and interprofessional relationships with care coordination stakeholders.

8. Analyze current available interprofessional team providers and resources.

. Competency 4: Recommend care coordination standards of practice for working with stakeholders.

9. Recommend technology-based outreach strategies supported by evidence-based research.

. Competency 5: Determine components of an effective, culturally competent, diversity-aware care coordination environment.

10. Describe a specific population need and the community.
11. Identify areas of cultural competency the team must address.

. Competency 7: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.

11. Communicate effectively in an appropriate form and style, consistent with applicable professional and scholarly standards.

• SCORING GUIDE

Use the scoring guide to understand how your assessment will be evaluated.

VIEW SCORING GUIDE

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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 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 Defining a Gap in Practice Executive Summary Paper Example

NURS FPX6614 Assessment 1 Defining a Gap in Practice Executive Summary

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

Course: NURS-FPX6614 Structure and Process in Care Coordination

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

Assignment Overview

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

Understanding Assignment Objectives

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

The Student’s Role

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

Competencies Measured

This assignment measures several key competencies:

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

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:

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

. Standard 1: Assessment.

. Standard 2: Nursing Diagnoses.

. Standard 3: Outcomes Identification.

. Standard 4: Planning.

. Standard 5a: Coordination of Care.

. Standard 5b: Health Teaching and Health Promotion.

Assessment Summary

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

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

Grading Criteria

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

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

. What is the PICOT question?

. Provide and explanation of the selected gap.

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

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

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

. What are the planning steps for the intervention?

. What expected outcomes you want to achieve?

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

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

Additional Requirements

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

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

Competencies Measured

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

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

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

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

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

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

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

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

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

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

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

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

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

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NURS FPX 6612 Patient Discharge Care Planning Paper Example

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

NURS FPX 6612 Patient Discharge Care Planning Paper Assignment Brief

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

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

Assignment Overview

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

Understanding Assignment Objectives

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

The Student’s Role

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

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

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures Presentation Example

NURS FPX 6612 Assessment 2 Quality Improvement Proposal Example

NURS FPX 6612 Assessment 4 Cost Savings Analysis Example

NURS FPX 6612 Patient Discharge Care Planning Paper Example

Introduction

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

Longitudinal, Patient-Centered Care Plan

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

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

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

Data Reporting

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

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

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

Client Records Influencing Health Outcomes

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

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

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

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

Conclusion

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

References

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

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

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

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

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

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

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

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

Description

Assessment 3 Instructions: Patient Discharge Care Planning Paper Assignment

PRINT

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

SHOW LESS

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

Research Resources

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

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

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

Note:

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

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NURS FPX 6612 Triple Aim Outcome Measures Presentation Example

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures Presentation

Assignment Brief: NURS FPX 6612 Triple Aim Outcome Measures Presentation

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

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

Assignment Overview

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

Understanding Assignment Objectives

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

The Student’s Role

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

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

NURS FPX 6612 Assessment 2 Quality Improvement Proposal Example

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning Example

NURS FPX 6612 Assessment 4 Cost Savings Analysis Example

NURS FPX 6612 Triple Aim Outcome Measures Presentation Example

Title Slide

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

Speaker Notes:

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

Purpose Slide

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

Speaker Notes:

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

Definition of Triple Aim Outcome Measures Slide

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

Speaker Notes:

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

Experience of Care/Patient Satisfaction Slide

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

Speaker Notes:

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

Improving Population or Community Health Slide

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

Speaker Notes:

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

Decreasing Per Capita Costs Slide

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

Speaker Notes:

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

Analyzing Relationships Between Health Models and Triple Aim Slide

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

Speaker Notes:

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

Structure of Health Care Models Slide

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

Speaker Notes:

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

Evidence-based Data Shaping Care Coordination Process Slide

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

Speaker Notes:

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

Governmental Regulatory Initiatives Slide

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

Speaker Notes:

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

Process Improvement Recommendations to Stakeholders Slide

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

Speaker Notes:

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

References Slide

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

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

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

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

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

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

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

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

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

Description

Assessment 1 Instructions: Triple Aim Outcome Measures Presentation Assignment

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

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