NURS FPX 6614 Assessment 1

NURS FPX 6614 Assessment 1

NURS FPX 6614 Assessment 1 Defining a Gap in Practice: Executive Summary

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Efficient healthcare delivery can be possible only through smooth overall conduct of services by all healthcare related bodies, consisting mainly the patients with multi-faceted health issues. Care coordination, as organized efforts to purposefully integrate patient care events pertaining to two or more of the healthcare entities involved in a patient’s care, unites placed among the cornerstones of achieving optimal health outcomes, enhancing patient experience, and checking the healthcare costs (Agency for Healthcare Research and Quality, 2019). Specifically, coordination of care processes is given a lot of weight to with even its effect being recognized. Still, it leaves gaps within the processes of delivery quality and patient-focused care. The goal of this executive summary is to bring to light the major flaw in care coordination process focus on home care, under the provision of healthcare for an elderly patient who is transitioning from hospital to home.

Clinical Priorities for a Specific Population

In light of providing elderly patients transitioning from hospital to a home care facility, it is essential to learn about their complicated health requirements in detail. Often, they demonstrate a range of chronic conditions characterized by hypertension, diabetes, and heart disease and because of this, these conditions always need management and collaboration between the healthcare providers (Schoenborn & Heyman, 2021). Moreover, current physiological changes due to aging and constant management of medications render this audience an even more complex one to serve (Boland et al., 2020). However, this period of transitioning from hospital to home care is very important as the elderly patients are at risk of disadvantages. Coordination is an essential process, and without it, they run the risk of wrong medications, adverse events, or continuity of care gaps (Kripalani et al., 2019). Helping with improving the functional decline after hospitalization is another important task, in what case elderly people can have reduced mobility, as well as cognitive deficits and higher fall risk.

  • Identifying Information Gaps:

These health professionals commonly stress on every aspect of patient care. Though a few areas may be troublesome for the elderlies after their hospital discharge, in general, there is no mounting issue in the home care provision for the elderly transitioning from the hospital to home care. One mistake firstly is diversity in policy development: their implementation. Hence, a standardized framework permits healthcare professionals to have a holistic evaluation of the person’s health and nonmedical requirements and to address both factors not necessarily recognized as concerning the illness outcomes (Steiner et al., 2019). Moreover, it is also problematic in terms of communication among mixed function departments. One of the major causes which leads to the growing amount of disconnected information and inconsistent care delivery is poor communication among different healthcare providers.

PICOT Question to a Gap in Practice

Among the hospitalized geriatric patients rehabilitating at home, do the standardized care coordination protocol programmes matter, and end in patient observation, healing, indicators, individual satisfaction and readmission rates over 12 months than traditional care pathways?

  • Rationale and Supportive Evidence:

The need for change in patient care coordination procedures, for elderly patients when they are being discharged from hospital to home care becomes evident when an acute gap is noticed in the current processes. In addition to the fact that many clinical studies are focused on the benefits of integrated care and the betterment of patient outcomes, the importation of standardized care coordination can also be verified by these studies. Forster and his colleagues discovered in their study of 2020 that coordinated care standards decrease the hospital readmission rate of the aged with significant numbers (Forster et al., 2020). The study noted that through improved communication among healthcare providers and the implementations of systematized discharge planning had led to an obvious reduction in readmissions in the first 6 months discharge period. Systematic researches by Shepperd et al. (2019) reveal that standardized care coordination has a significant influence on enhancing patient satisfaction. Through these strategies, equal access, guaranteeing follow up appointment dates and thorough discharge instructions, older patients had higher level of satisfaction of their care than they could have.

Potential Services and Resources for Care Coordination

Consideration of available services and resources for elderly care coordination during hospital – home transitions calls for an interactive process. Several programs and resources provide assistance for this population in obtaining the care necessary for primary care providers to coordinate effective treatments. Navigators that are patients are an invaluable asset to unexpected patients who work with them to remove obstacles to accessing provided services and to ensure appropriate communication between all providers. Through this intermediaries who can help to book appointments, transportation coordination, and working through complicated healthcare systems, these individuals can be a major help to the patients. Community health workers, competent in offering culturally sensitive support and education, can be of great help to elderly with chronic conditions in that they can teach them how to use community resources, manage the diseases and practice self-care styles, among other services.

  • Barriers to Care Coordination:

Despite all the opportunity that is on the table, the existence of obstacles such as the absence of system for the delivery of healthcare combined with limited access to technology, healthcare disparities and insufficient workforce acts as hits to healthcare coordination effectiveness. The impact is multiplying as the factors become more scattered, with resultant gaps in care, and a mix of restricted technology access and inequality further limiting access to services. Workforce shortage intensifies the continuity deficiency.

  • Supportive Scholarly Resources:

Smith, et al., (2020) have proved patient navigators to have a positive impact in addressing hospital readmissions, and most notably by shedding light on the critical part of community health workers in resolving the social determinants of health matters. (Greenhalgh et al.2019) envision the role of telehealth in increasing access to care options, nevertheless, Usage and integration of technologies by patients can be a challenge.

NURS FPX 6614 Assessment 1

Type of Care Coordination Intervention

In assessing the degree of care coordination that can enhance evidence-based practice in elderly patients who are being discharged from a hospital and transferred to home care, what remains critical in all instances is a multi-disciplinary approach that is guided by standardized protocols and which focuses on the patient’s well-being.

Specific and Practical Ways of Addressing the Intervention:

  • Interdisciplinary Care Teams:

Coordinating between medicine and other health disciplines teams so that that a specialist team such as physician, nurses, social workers, pharmacists, and other healthcare professionals can assess and manage complex issues of the older population(s). The teams engage in the joint endeavor of devising of the individual care plans, coordination of services, as well as giving the essential aftercare support during the transition time.

  • Structured Care Transitions:

Incumbence upon standardized protocols to be applied to care transitions, such as detailed discharge planning, and coordination of medications throughout the discharge and post-discharge care period, significantly decreases the risk of bad outcomes. Applying evidence-based strategies like the CTI and the RED protocol will ensure the continuity and the quality of care through six main components.

  • Patient and Caregiver Education:

Learning self-management techniques, taking medications on time and being able to notice the possible complications are the educational goals passed to the patients and their caretakers. That way, they can participate in the process of their recovery after discovery and be assured their successful recovery. For instance, the strategy of teach-back, the use of written materials, and content tailored to the health literacy levels of individuals improve the effectiveness of educational strategies.

Summary of Selected Nursing Diagnosis

For the collaborative case, the nursing diagnosis chosen is “Risk for Imparied Transition Management,” which covers the factual hazard risk factors during the course of transition such as: medication errors, the inadequacy of the follow up care, and the lack of social support.

Supporting Strategies and Best Practices:

  • Medication Reconciliation:

Detailed medication reconciliations upon admissions and discharges can identify various types of mistakes and make it unlikely for those mistakes to be transmitted upon the patient’s discharge. The use of electronic health records (EHRs) as well as well specified protocols guarantee safety and agreement in medication managements across care settings.

  • Structured Discharge Planning:

Providing streamlined discharge planning procedures such as patient education, treatment agents recommendation, and links to further checkups ensures sustained care hence the risk of misadventures after the discharge is minimized. Using instruments like the teach-back technique and written a discharge instruction the patients’ understanding of the purpose of the care plan is improved as well as resulted adherence.

  • Multidisciplinary Care Coordination:

The involvement of interdisciplinary care teams that include such professionals as nurses, doctors, pharmacists, nurses, and other health care workers leads to the development of unified approaches for assessing and managing the needs of a patient. Collaborative care rounds, interdisciplinary meetings as well as care conferences are all tools that improve communication between different patient providers. This communication results in the patients having a smooth of passage from one care provider to another.

Planning of the Intervention And Expected Outcomes

The elderly patients being transitioned from the hospital to home care will benefit from the scope and standards of practice that care coordination involves. It starts via a complete evaluation of patients`their desires (Smith et al., 2020). Through this evaluation, specific goals are formulated and interventions based on research evidence are chosen which include the standardized protocols for a patient-centered care plan, medication reconciliation, and education of patient. Implementation means that it involves organically organized cooperation among healthcare providers, patients, caregivers and community resources.

  • Expected Outcomes:

The program is forming to decrease the number of hospital readmissions and maintain the patients’ satisfaction level as well by improving the health care quality (Shepperd et al., 2019). In addition, it related to medication management competency, therefore it helps patients to take drugs appropriately and avoid drug side effects. Lastly, the program aims to broaden the availability of the local resources which eventually helps smooth sailing of transitioning from one level to another and build a support system in the community.

  • Assumptions and Suggestions for Improvement:

Assumptions involve the understandability of the intervention, including the preparedness of healthcare providers, patients, and caregivers to assume a proactive role. This issue can be confronted through investing in education and training for staff, resourcing the implementation of new policies, and setting up effective support systems. An ongoing quality improvement featuring the evaluation exercises and consideration of key stakeholders’ views is a prerequisite to the optimal operation.

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NURS FPX 6612 Assessment 1


In conclusion, it can be said that the article, written with a huge consideration of all features of the given assignment that demands a definition of a gap in professional practice dealing with coordination care for elderly patients who are leaving hospital for home care, is composed appropriately. The PICOT question, as well as the examination of clinical priorities and potential service and resource options, the appraisal of care coordination strategies and the planning of intervention tools is a summaries all described aspects of the found problem and solution. Moreover, the summary includes up-to-date referenced sources from reputable journals and books published not later than 2019, presenting crucial information and guaranteeing credibility of the proposed interventions. It is consonant with the purview and the literature review for care coordination and the summary offers evidence based practices and strategies for tackling the selective problem identified.


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