NURS FPX 6616 Assessment 1

NURS FPX 6616 Assessment 1

NURS FPX 6616 Assessment 1 Community Resources and Best Practices

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Hey everyone, my name is (Student), and I will be your host for today’s discussion on enhancing care management of challenging patients in the healthcare groups in our neighborhood.

The community tools and best practice are the things, services, and treatments that promote healthy and positive well-being that are available in the community. In order for healthcare groups to be able to give systematic, comprehensive care, they have to seek and implement local resources and benchmarks. They can also assist patients to access some of the services such as meal programs, support groups, home care and transportation among others. Consensus, which is something that has been demonstrated by science to work as well as possible, helps to ensure that care is high quality and not too expensive. For instance, transitional care models that include home visits and follow up after discharge from hospital are known to reduce the admission rates (Cassetti et al. , 2019). Health leaders can identify their capacity to address the needs of patients with reference to community tools and benchmarks. It also empowers them to be able to look at the market and find new ways of satisfying unfulfilled demands.

  • Scenario

Christina is 32 years old female who has Type 1 diabetes for 5 years. An average HbA1c of 9 is not an optimal level of diabetes control, and this may be even worse for patients with more complications and longer duration of the disease. The increase 2% over the last two years is higher than the ADA recommended level of less than 7% (American Diabetes Association, 2024) However, even though Christina strictly adheres to her insulin regimen, her overall glucose regulation could be better. She also suffers from microvascular complications of diabetes including background diabetic retinopathy and peripheral neuropathy where her feet are painful and feel numb. Christina’s family was recently forced to take her to the hospital because she contracted Diabetic Ketoacidosis (DKA) due to getting food poisoning and developing gastroenteritis. The fact that she often gets hypoglycemia which has impact on her work and social life indicates that she needs to enhance the way she deals with the disease. Lack of money and her tight working schedule leaves her with limited options when getting care. Since Christina has a severe condition of the disease, it leads to a number of complications and she is unable to manage herself well, she requires a lot of medical and personal assistance to recover.

Ethical Issues Regarding Health Information Systems

Integrating the health information systems to coordinate Christina’s care across her primary care physician, endocrinologist, ophthalmologist, podiatrist, and therapist raises some crucial ethical concerns regarding confidentiality and the proper ways to share personal health information. As mentioned by Keenan et al. (2020), data sharing in a way that is acceptable should be from a principle of liberty, beneficence, and justice. This will assist in the better co-ordination of care. Before the care team of Christina can disclose private information that pertains to her diabetes issues, mental and emotional problems, he or she must obtain her consent. On the other hand, sharing data enable early intervention, collaborative approach to treatment and better health outcome which is beneficial for Christina and reasonable way of allocating healthcare resources (Lawless et al. , 2020).

To address these moral issues, Garg et al. (2021) recommend role-based access controls that allow only those healthcare workers who require precise patient data for their duties to access it. For instance, Christina has a doctor who wants to know if she suffers from any ailment that would cause nerve damage in her lower limbs than care about her history of mental illness. It prevents people from using the information without consent from the patient, but at the same time, allow people to share information in an orderly and ethical manner that would benefit Christina. Other effective consent processes that should always be evolving are also essential so that Christina can always be aware of when and how her health information will be shared.

Legal Issues of Current Practices

HIPAA allows Christina to maintain the privacy of her PHI and access it when she requires under Health Insurance Portability and Accountability Act. When she has to go to a new expert, the requests for medical information must be faxed or mailed in, which is time-consuming when it comes to organizing care. According to Esmaeilzadeh (2022), health care providers are reluctant to adopt digital health information sharing due to privacy concerns. However, suggested electronic health record systems that allow users to access data in real-time are HIPAA compliant if they incorporate security features such as log audits, encryption, and tools for permission of patients. They make it convenient for doctors to come up with quick decisions and plan on how to treat complicated cases such as Christina’s, which is healthy for her legally.

Some of the legal issues that may arise in case better care planning for patients such as Christina is done include the following: mistakes arising from old or even damaged records (Basilicata et al. , 2022). According to Mouttham et al. (2020), ongoing quality assurance should be carried out through the data audit and training of teaching providers on how to record items appropriately. From our analysis, improved teamwork is not associated with much more risk, provided that the proper safeguards are put in place to ensure that Christina’s multidisciplinary care team can exchange data safely and effectively and without compromising the treatment timeline. Thus, by adhering to the HIPAA rules and guidelines, doctors can still legally work with full data, enhancing the quality of care in the right medical and legal context.

Current Outcomes and Best Practices Outcomes

Christina’s high and irregular blood sugar levels, diabetes retinopathy, and nerve damage are all attributed to her not receiving proper care coordination. Integrated care programs also provide the individualized attention that is required by the complicated cases of diabetes in order to manage their blood sugar levels. One study reported that HbA1c reduced from 9. 4% to 7. When joint care teams and health information systems were used to enhance teamwork then it was at 0% (Hinsky, 2020). Endocrinology, vision, podiatry, mental health services, and diet support are all going to have to be heavily involved with Christina. For a more proactive approach, the following guidelines are recommended: Writing of care plans and integration of health information, and case conferencing.

Another useful suggestion is to incorporate the change of care models in Christina’s release plan following her acute DKA attacks. According to Coppa et al. (2021), among the patients who were readmitted within 30 days, 18% did not have a follow-up plan in place. On the other hand, LeBar (2020) employed the use of online tracking tools and seeking the assistance of a nurse after release to minimize readmissions. Reducing patient readmissions decreases their suffering and enhances their quality of life while also reducing expenses. In summary, with the help of current evidence-based approaches in telecare, information exchange, and transitional care across Christina’s interdisciplinary team, it is possible to enhance the results in such aspects as glucose fluctuations, the severity of diabetes complications, functional status, mental health, and healthcare consumption.

Evidence-Based Intervention

A Patient-Centered Medical Home (PCMH) is another model that has been identified to effectively address the needs of Christina and her complicated diabetes care. According to Rittenhouse et al. (2020), a PCMH is a centralized primary care center that collaborates with specialists with the help of health IT and data analytics. The main components are care coordination staff, computer advice which enables the specialists provide more prompt advice, Patient medical records that are centralized, tools that allow for online monitoring of patients, tracking of ongoing quality improvement. Studies also indicate that PCMHs increase the rate of guideline compliance, patient satisfaction, and glycemic outcomes for type 1 diabetes groups such as Christina (Shah et al. , 2023).

The first and most significant PCMH strategy that will facilitate Christina’s care changes is a nurse care manager. This person will be responsible for arranging her liberation after acute episodes. Care managers ensure all her doctors are informed of the treatment plans, ensure she has post-discharge visits, and monitor her remotely for issues through apps. This has resulted in a reduction in the 30-day return rates as noted by Minervini et al. , (2022). Having a role that is responsible for care management across stages allows people to return to self management after being hospitalized and can prevent issues that may arise while in the hospital. For example, the PCMH’s structured data access and tracking also allows Christina’s care managers, endocrinologists, and the primary care team to safely collaborate under HIPAA.

NURS FPX 6616 Assessment 1

Role of Stakeholders and Interprofessional Team

Based on the details of Christina’s case, it implies that the management of her diabetes requires a team of practitioners from different fields. According to Alderwick et al. (2021), joint care models mean the engagement of a diverse range of partners to enhance outcomes and integration. As Christina’s Primary Care Provider (PCP), I would be Christina’s Primary Care Provider (PCP), and therefore, would be in charge of her whole person care and leading her care team. The endocrinologist would then have to consult the nurse staff so that the patient’s insulin plan was correct and any issues were addressed. Podiatry and ophthalmology provide the feedback to track neuropathy and blindness. A mental health counselor works with psychological disorders that affect an individual’s capacity to manage his or her own existence. Dietitians can assist in the matter of diet in order to prevent the worsening of the symptoms. As we have discussed, employing a specialized care manager will ensure that all the people who surround Christina, a large care circle, will coordinate properly.

For merger to go through effectively, the management of the two companies must be prudent when it comes to use of resources. Administrators in the healthcare sector must foster proper organizational interactions to ensure that all the stakeholders are able to contribute towards attaining value based community health objectives (Kokshagina, 2021). For Christina, this implies that the IT staff maintains effective data security and access measures to ensure that her providers can access the necessary health records while conforming to HIPAA legislation. Clinical leadership establishes fact-based management tools that are applied in all sectors. In order to support combined decision-making, administrative teams planned meetings and agendas for the providers. When Christina’s multidisciplinary team defines stakeholders’ roles and responsibilities, they can enhance health outcomes.

Use of Data-Driven Outcomes

In order to find out how the care coordination program influenced Christina’s health, it is pertinent to monitor several clearly defined result indicators in the course of time. Soh et al. (2020) listed the following as the key diabetes outcomes: HbA1c, blood pressure, lipid profile, the presence of microvascular complications, cardiovascular risk factors, hospitalization and re-admissions, emergency department visits, and patient self-reported outcomes including quality of life. Her care team should monitor these signs every 90 days to assess how effectively she is managing her diabetes and her overall condition. Her endocrinologist can tell how well the insulin plan is working by watching how the complications are progressing, her primary care doctor can oversee her mental and social well-being, and a care manager can monitor her healthcare usage.

According to Godillot et al. (2020), patient experience surveys that are approved should be conducted at least twice in a year to enhance outcomes studies. Christina is asked a series of questions concerning the integration of care, changes, patient-provider contact, and her confidence to manage her diabetes. All of those are critical components of care coordination. Opinion of the patient when combined with health signs covers all the aspects of the situation. If things get worse, my care team is aware of gaps that must be covered in better communication. It would mean that daily data tracking can set success indicators such as HbA1c <8, no further blindness, 50% reduction in numbers of hospitals, and average patients’ satisfaction higher than 80% (Kuniss et al. , 2021). This method is founded on data and this will help to determine the exact time and way through which collaboration can be enhanced for the overall wellbeing of Christina.


To achieve sustainable benefits from teamwork, my team applies several strategies, which are under expansion. First, Damarell et al. (2020) affirm that making frequent meetings with the patient formal enhances collaboration. This care network meets every three months for Christina’s holistic assessment of health. Treatment is altered based on new test results, stated concerns, and data points regarding changes in the outcome measures. Her insurance plan also covers annual physicals for all of her chronic illnesses to identify needs as they wish. Second, patient platforms and video apps that allow people to monitor their progress between visits are supported by Hoefer et al. (2021). Portals enable Christina and her care circle to share information freely, while glucometer and blood pressure uploading lets people follow her condition from a distance.

This makes sustainability even stronger by having continuous quality testing programs. Tihitena Negussie Mammo et al. (2022) effectively reduced readmissions as managers reviewed one random group of discharge reports monthly, reminding them on the coordination process when necessary. This might entail reviewing with Christina how she plans on getting home from the hospital and ensuring that there are enough follow-up appointments and other related services. As Shah et al. (2023) rightly point out, it is crucial to periodically assess the key effective coordination practices across her care environment; this, along with providing team training, brings lasting changes and helps prevent integration efficiency from gradually declining. By keeping Christina’s multiple data analysis from the integrated network as well as open conversation platforms and quality assurance processes permanent, results will remain the same.


This entails assessment of the current practice, implementation of effective treatment that are backed by research data, constant evaluation of the outcomes attained and ensuring that the processes of sustainment are as effective as possible. Read Christina’s story to learn how fragmentation of care delivery harmed her physical well-being and eroded her self-assurance. Thus, the patient-centered medical home with the centralized health data, the teams of physicians and nurses, the web-based tools for monitoring, the focus on patient’s dedicated care, and the continuous quality improvement programs can help her care ecosystem to foster self-care in many ways and enhance the disease markers.
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NURS FPX 6616 Assessment 2


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