- NURS FPX 6614 Assessment 1 Defining A Gap In Practice Executive Summary.
Defining a Gap in Practice Executive Summary
This summary will analyze clinical priorities for the Medicare-approved hip and knee replacement population to influence health outcomes utilizing care coordination processes with a PICOT question addressing a gap in practice for care coordination. Care coordination services and resources available for this population will be evaluated using evidence-based practice care coordination interventions to best care for this population. A selected nursing diagnosis will maintain a collaborative care strategy with a conversation of intervention planning and expected outcomes for the care coordination process using the degree and standards of practice for care coordination. Explore our assessment NURS FPX 6614 Assessment 2 Enhancing Performance as Collaborators in Care Presentation for more information.
Clinical Priorities for Lower Joint Replacement Population to Influence Outcomes
Many hospitals require their Medicare-approved lower joint replacement medical strategy patients to attend pre-surgical education with the care coordination team. This pre-medical way of thinking education’s primary place is to assess and address any social determinants of health(SDOH) patients may be experiencing before a medical framework in solicitation to improve kid care quality, avoid discharge delays, control costs after hospital discharge, and forestall readmissions(Centers for Medicare and Medicaid Services, n.d.).
Hospitals are penalized for under 30-day readmissions and gifted nursing facility(SNF) spending, and how hospitals decide to decrease these expenses is their choice (Zhu et al., 2018). Hospitals are moving more toward locally situated care. They are hiring dedicated care coordination staff like local area health workers(CHW) to continue to follow up on patient care once gifted home health services are discontinued to guarantee patients continue with their home care plan(Zhu et al., 2018).
The guidance of CHWs assists patients in keeping follow-up appointments and helps with any necessary resources, including monitoring and reporting health outcomes to the primary physician or specialist. CHWs are a part of a collaborative team; for example, they support cases. Managers, social workers(SW), and dieticians who work behind the scenes from medical practices to assist patients with high gamble or complex care needs to decrease high crisis department (ED) utilization and readmissions.
Zhu et al., 2018 report that there is a great deal of literature reporting on the advantages of locally situated care utilizing CHWs, yet there is a gap in knowing whether home discharges post-medical strategy without assistance from CHWs could increase hospital readmissions or harm patients with more mind-boggling needs(p.1286).
PICOT Question
In adult patients with total lower joint replacement medical procedure (Population), how compelling is the utilization of CHWs in locally established care after a medical strategy (Intervention) compared to home discharges without the utilization of CHWs (Comparison) in improving quality of care and recuperation (Result) during the postoperative and recuperation time (Time)? This inquiry is central to NURS FPX 6614 Assessment 1 Defining A Gap In Practice Executive Summary, as it explores the impact of CHWs on patient recovery and care quality in postoperative settings.
Selected Gap Explanation
Once discharged from the hospital to home and when talented services are finished, the real battle is getting the patient to participate in their care for a significant length and maintain compliance with the healthcare plan and follow-up appointments(Kangovi et al., 2020). The assumption can not be made that all CHW’s efforts will forestall unnecessary (ED) visits.
There will always be behaviors that can not be changed, patients who will not participate in care coordination and remain defiant, and individuals who continually make unfortunate healthcare choices(Zhu et al.,2018). Zhu et al., 2018 also report that they did not interview care coordinators or CHWs whose viewpoints may contrast with those of healthcare suppliers and specialists regarding their viewpoints concerning the impact of utilizing CHWs or not in the homes of postsurgical patients(p.1284).
Available Care Coordination Services and Resources
Care coordination with the patient and family starts before a medical strategy. The specialist’s office collaborates with hospital case managers, surgical unit medical attendants, home health liaisons, physical therapists, and pharmacists to make each small move toward turning joint class education into planned joint replacement patients. The workplace medical framework scheduler arranges the patients’ many weeks of education classes. Patients attend the class in the hospital, so they know exactly where to go on the day of the medical approach.
NURS FPX 6614 Assessment 1 Defining A Gap In Practice Executive Summary
A plunk-down conversation is held, and each hospital discipline talks with the patients and any family who attend to examine a medical strategy, home-going expectations, medications, social determinants of health(SDOH), caregiver work, and durable medical equipment(DME). A question-and-answer meeting for the patients and families is introduced at the finish of the class. The goal is to meet face-to-face with patients and families, assess needs, and prepare patients for home-going to avoid unnecessary discharge delays and talented nursing facility(SNF) referrals(Mendel et al., 2018).
This pre-medical framework education also assists patients with planning pre-medical strategy interventions and educates them on expected outcomes after medical technique. Patients and families get education regarding transitions to a CHW once talented services are finished. In this collaborative relationship with patients and families, a feeling of trust is created with their supplier, and patients meet a team who will be caring for them in the hospital, which gives a sense of strengthening to patients and families(Zhu et al.,2018).
Evidence-based Care Coordination Intervention
The care coordination guidance given to the Medicare-approved hip and knee replacement population is based on The Selected Attendant Care Coordination Transition Management Model (RN CCTM). The American Academy of Ambulatory Care Nursing (2016) states that this model has brilliant light on individualized patient-focused assessment and care planning and advanced to standardize all selected medical attendants’ work using evidence from nursing and interprofessional literature on care coordination and transition management(p.8).
Care Coordination and Transition
The RN CCTM model brilliantly highlights care coordination and multidisciplinary team collaboration. It offers an individual-focused approach to patient care to engage and encourage patients to collaborate with their healthcare suppliers. A critical part of care coordination is preparing for the transition management of care, and this is where the utilization of CHWs plays a task. Transition management assists patients and families as they navigate their longitudinal healthcare journey(The American Academy of Ambulatory Care Nursing, 2016).
Care coordination is about assessing individual care needs, tailoring care to that patient, identifying patient dangers, and, based on those dangers or necessities, continuing care services the most appropriate for the transition management care.
Nursing Diagnosis
Readiness for Enhanced Individual Coping is evidenced by verbalizing the desire for information from a local health coach that will enhance optimal health outcomes and further cultivate healing(Phelps et al., 2017).
Issue Assessment
The patient will display a readiness for enhanced individual coping by collaborating with the care coordination team and expressing a willingness to accept further assistance from the CHW to achieve optimal health outcomes. The patient will deal with healing by maintaining follow-up appointments and accepting local area resources and guidance from the CHW.
Planning Interventions and Expected Outcomes
A multidisciplinary collaboration needs to begin at the start of care, not sometime before the transition, including the patient and family(American Academy of Ambulatory Care Nursing, 2016). Then, care coordination necessitates seeing patients in danger of unnecessary readmission or ED utilization by assessing health literacy, SDOH, trust in taking care of oneself, the intricacy of any comorbidities, and their discharge condition(American Academy of Ambulatory Care Nursing, 2016).
NURS FPX 6614 Assessment 1 Defining A Gap In Practice Executive Summary
Lastly, transitional planning is more than the patient’s discharge instructions; it involves coordination with all of the appropriate care suppliers necessary to guarantee that the patient is transitioned home with understandable discharge instructions and home health services and determining the essentials for a CHW once talented services are complete(American Academy of Ambulatory Care Nursing, 2016).
Patient-Centered Care Outcomes
To achieve outcomes for patients and families, the goals should be achievable based on their inclinations and values, and it is essential to include them in choice-making (American Academy of Ambulatory Care Nursing, 2016). Expected outcomes will be evidenced by patients and families verbalizing understanding of alluded local area resources and maintaining follow-up appointments arranged by CHW(American Academy of Ambulatory Care Nursing, 2016).
The family and patient will accurately portray the disease interaction, feelings about self-management of their healthcare, and healthcare follow-up (American Academy of Ambulatory Care Nursing, 2016). In NURS FPX 6614 Assessment 1 Defining A Gap In Practice Executive Summary, outcomes will coordinate care across the healthcare continuum using an all-encompassing, individual-focused, evidence-based approach to attaining patient goals (American Academy of Ambulatory Care Nursing, 2016).
References
American Academy of Ambulatory Care Nursing (2016). Scope and Standards of Practice for Registered Nurses in Care Coordination and Transition Management. 1-40. https://ebookcentral-proquest-com.library.capella.edu/lib/capella/detail.action?docID=4768806#
Centers for Medicare & Medicaid Services. (n.d.). BPCI Model 2: Retrospective acute & post-acute care episode | CMS innovation centre. CMS Innovation Center CMS Innovation Center. https://innovation.cms.gov/innovation-models/bpci-model-2
Kangovi, S., Mitra, N., Grande, D., Long, J. A., & Asch, D. A. (2020). An evidence-based community health worker program addresses unmet social needs and generates positive returns on investment. Health Affairs, 39(2), 207-213,213A-213C. doi:http://dx.doi.org.library.capella.edu/10.1377/hlthaff.2019.00981
Mendel, P., Chen, E. K., Green, H. D., Armstrong, C., Timbie, J. W., Kress, A. M., Friedberg, M. W., & Kahn, K. L. (2018). Pathways to Medical Home Recognition: A Qualitative Comparative Analysis of the PCMH Transformation Process. Health services research, 53(4), 2523–2546. https://doi.org/10.1111/1475-6773.12803
Naylor, J. M., Hart, A., Harris, I. A., & Lewin, A. M. (2019). Variation in rehabilitation after uncomplicated total knee or hip arthroplasty: A call for evidence-based guidelines. BMC Musculoskeletal Disorders, 20 doi:http://dx.doi.org.library.capella.edu/10.1186/s12891-019-2570-8
Phelps, L. L., Ralph, S. S., & Taylor, C. M. (2017). Sparks and Taylor’s Nursing Diagnosis Reference Manual (Tenth rev. ed.). Wolters Kluwer Health.
Zhu, J. M., Patel, V., Shea, J. A., Neuman, M. D., & Werner, R. M. (2018). Hospitals Using Bundled Payment Report Reducing Skilled Nursing Facility Use And Improving Care Integration. Health Affairs, 37(8), 1282-1289,1289A-1289B. http://dx.doi.org.library.capella.edu/10.1377/hlthaff.2018.0257