NURS FPX 6616 Assessment 2

NURS FPX 6616 Assessment 2

NURS FPX 6616 Assessment 2 Defining a Gap in Practice: Executive Summary

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In this dynamic setting, it becomes vital to recognize many practice deficiencies that should be addressed for the sake of better patient outcomes and limitation of equipment utilization. This executive summary serves as a foundational document to delineate a specific gap in practice related to care coordination for a vulnerable population: patients who are elderly and with chronic diseases (Smith, 2020). This summary aims to address this particular gap by outlining the recommended targeted intervention. This should help healthcare institution policymakers in decision-making after strategizing. The above possibility will be a major booster of the patient care and interprofessional collaboration. We will dive deep into the complexities of pushing care integration for elders having multiple chronic disorders, underlining the problems they face and the outcomes of healthcare. Through the question posed in the PICOT framework, utilization of available resources, and the recommendation of a well-thought-out program, this summary of the executive report is aimed at providing decision-makers with useful steps to improve care coordination processes and hence enhance care quality for these patients.

Clinical Priorities

It is of major relevance to assess the clinical priorities of a certain population, say, disease management for the older people with chronic diseases, as a mean to improve the health outcomes in a care coordination process. This entails involving the health problems the target group is grappling with, understanding the specific needs of the given population, and acknowledging the points of potential hindering the provision of quality healthcare service delivery. Through the lens of acute care patients having chronic issues, these priorities show up Chronic Disease Management stands out as the key issue which very often gives the elderly patients a challenge of dealing with multiple health issues. For example, hypertension (high blood pressure), diabetes and heart issues among others. The primary emphasis on treating and managing such conditions is to prevent complications, to decrease hospitalizations and to sustain the individual’s functional capacities. Nevertheless, it is widely accepted that Medication Management becomes crucial because polypharmacy and difficulties related to medication adherence are widespread among the elderly populations (Johnson & Brown, 2019). Theo a coordinated strategy encompassing medication reconciliation, education, and monitoring is very essential as far as medication is concerned. Another action area is the prevention section which takes into account the increased risk of infections or other preventable health concerns among elderly people (Garcia et al., 2021). The use of preventive measures at the forefront like immunizations, cancer screenings, fall prevention and others could be a huge step towards lowering the risk of disease and improving the overall health of the population. In addition, Functional Independence support occupies a top place, including implements to conduct activities of daily living, mobility, and sociability, and then helping seniors be mostly independent.

PICOT Question to a Gap in Practice

  • PICOT Question:

Among the elderly with chronic conditions (P), does proper care coordination program (I) that involves comprehensive approach (C) compared to routine care (O), influence health outcomes associated with their readmission to hospitals, compliance to prescribed regimen and quality of life (O) over six months (T)?

  • Explanation:

The fact that the elderly patients with chronic conditions that experience fragmented delivery of healthcare services is vivid through loads of evidence showing that the care coordination in the elderly patients with chronic conditions in the few years has not been improvement while their outcomes is very bad. Vast evidences show that discontinuity in care like readmissions (Adams et al., 2019). Implementation of patient care coordination program, as seen in some cases, acts as a base for addressing the existing gaps in the healthcare system by improving the communication within healthcare providers, offering more patient education and self-management support and coordinating the transitions of care (Report of Smith, 2020). This refer the factual evidence given by the American Medical Association role for care coordination in improving patients outcomes and improving efficiency of healthcare delivery.

By contrasting the processes of implementing a wide program that involves coordination of care vs. what was done before, healthcare organizations can judge the effectiveness of this intervention in healthcare outcomes improvement for elderly people with chronic diseases. Our PICOT question effectively provides a way to examine and have proof that this program is needed, and is supported by scholarly evidence showing that patient care coordination for this population has benefits.

Potential Services and Resources for Care Coordination

Finding out of the various services and resources needed to improve care coordination for elderly individuals with chronic diseases can be likened to a spectrum with both unfavorable and favorable conditions which are major obstacles in the effective coordination of their care. EHRs (electronic health records) paradigm is created which is the main platform for medical data storage and exchange across the healthcare so that collaboration and communication among healthcare workers is facilitated (Jones, S. M. & Smith, M. C. 2020). Not only interdisciplinary care teams staffed by different healthcare professionals act as care coordinators, reaching out to the vast scope of knowledge and skills necessary to meet the manifold requirements of older adults (Adams et al., 2019). Community Health Workers (CHWs) perform incredibly important work, with a focus on underserved populations, by ensuring that the community engages in health education through papoutsoulia and improving access to health care (Brown & Garcia, 2021). It is worth noting that telehealth services increase access to care by providing remote delivery of healthcare services and which play an important role in the management of chronic conditions, in which elderly patients are mostly affected (Martinez & Johnson, 2020). Yet while that is the case, the scientific community is currently facing several obstacles in the way of furnishing effective care coordination. Lack of health information systems interoperability held as one of the core problems, because it severely impacts the ability to jump electronically from one patient information system to another, as well as set up coherent healthcare delivery (Clark & White, 2019). A situation that is even more difficult to control is the lack of human resources, especially in rural areas, and insufficient training in the aspects of coordination among workers of healthcare facilities.

Type of Care Coordination Intervention

  • Assessment of Care Coordination Intervention for Elderly Patients with Chronic Conditions:

When eliciting the type of care coordination intervention that would be optimal to enrich evidence-based practice for senior patients with chronic conditions, it is fundamental to consider interventions that cover the complex needs of this group of patients and use from evidence-based protocols and the highest standards available. The following outlines specific and practical ways of addressing the care coordination intervention: The following outlines specific and practical ways of addressing the care coordination intervention:

  • Comprehensive Care Management:

The approach advocates for the assignment of care coordinators, namely – the registered nurses and advanced practice providers, effectively serving as the central point of contact and who orchestrating care for patients across multiple settings (Jones & Brown, 2020). This care coordinator pays a comprehensive assessment, customizes individual care plans, organizes services, and facilitates the monitoring of patients to ensure coordination.

  • Multidisciplinary Care Teams:

The multidisciplinary teams in which physicians, nurses, pharmacists, social workers and other rehabilitation specialists are present enable collaborative and informed decision-making and management of elderly patients who suffer from chronic diseases. The experts from these teams work closely together to provide for both the physical, psychological, as well as social needs of a patient and provide medication management, education and support for self-management of the condition.

NURS FPX 6616 Assessment 2

Summary of the Selected Nursing Diagnosis

The adopted nursing diagnosis of an elderly patient with chronic conditions is the HRQOL influenced by disintegrated health care system as well as insufficient self-management skills. Such chronic conditions as transversely present in the patients in the older age often cause to reduced QOL of HR because different barriers intercedie whereby provider-coordinated care is difficult to find, their conditions become too many and the healthcare system becomes very complex to overcome. Instead of targeted treatment, fragmented care escalates the symptoms, increases the healthcare demands that do not get attended to, and finally, takes away the all.

To handle successfully this nursing diagnosis and realizing high health-related quality of life, integrated care models that focus on the patients first, the teamwork, and the education of the patients be at the basis. Specific and relevant examples of strategies and best practices to support this summary include specific and relevant examples of strategies and best practices to support this summary include:

  • Patient-Centered Care Planning:

It is through involving patients in care planning processes that their power to make decisions has effectively enhanced and set objectives that they truly support. For instance, eliciting senior patients’ participation in the making of plans of care through shared decision-making tools like decision aids or conversations about advance care plans aim to sustain some level of autonomy and respect for treatment desires (Brown & Smith, 2020).

  • Interdisciplinary Care Coordination:

Creating intesected teams of physicians, nurses, pharmacists, social workers, and other paramedic staff that give complete assessment and treatment of elderly people with chronic illnesses greatly improves the outcome. Under the framework of joint meetings, care rounds, case conferences and care coordination team members can comprehensively share information, make coordinated plans, and address complex care needs effectively (Adams et al., 2019).

Planning of the Intervention and Expected Outcome

Organizing multi-disciplinary communication among all healthcare providers which includes physicians, nurses, pharmacists, social workers, and other rehabilitation professionals in order to make sure that the treatment provided is comprehensive and coordinated. Interdisciplinary collaboration is described in the span of the practise code and practitioner standards which encompass the critical role of efficient communication, teamwork, and mutual respect in achieving the desired patient outcomes (Adams et al., 2020). This involves education and continual support to help the people with chronic conditions to live their life to the fullest by themselves. The education interventions concentrate on the increased health literacy level, promoting medication compliance to the therapy, fostering healthy behaviors, use of shared decision making process among all patients and those providing healthcare. The strategy we adopt is consistent with care coordination practice standards and guidelines defined by the scope and standards of care, which stress on the responsibility of care coordinators in assisting patients in health engagement and promulgation.

Expected Outcomes:

  • Improved Health Outcomes:

Through conducting the planned intervention, we expect several health outcomes among elderly patients to improve, such as a reduction in hospital readmissions, enhancement of medication adherence, better control of diseases, and promotion of quality life.

  • Enhanced Patient Satisfaction:

Collaborative care planning with patients, education and support as well as patient-centered care are envisaged to cause an increase in patient satisfaction and the degree of their involvement into the care system.

  • Optimized Resource Utilization:

The intervention focuses on improving the coordination of care, preventing complications and encouraging self-management as a way of optimizing healthcare resource utilization and reducing overuse of healthcare utilization through services such as emergency department visits and hospital readmissions.

Assumptions Underlying the Analysis:

  • Assumption of Interdisciplinary Collaboration:

The scenario puts forward the presumption that the health care providers will actively cooperate with their counterparts in the sector and will follow evidence-based approaches. Effective communication and teamwork is the underlying factors for the success of the maintenance.

  • Assumption of Patient Engagement:

The study assumes that patients will be very engaged in their care and have a high level of motivation to practice self-management techniques. The educational and support interventions are the components of the program that largely guide toward more active patient participation, leading to better patient empowerment.

Insightful Suggestions for Improving Outcomes:

  • Continuous Quality Improvement:

Improving outcomes via an ongoing quality improvement process that includes frequent monitoring of where we’re succeeding and where we need to improve, and then following up to make those changes. It is crucial to realize regular monitoring of outcomes with feedback and aligning it for optimum results and for increasing the efficiency level of the initiative.

  • Utilization of Health Information Technology:

Employ health information technology especially electronic health records and telehealth for the communication and data movement to aid and ensure that there is seamless information sharing among various health care providers. The introduction of technology can provide ways to optimize productivity, minimize incorrect considerations, and actively involve patients in their treatment process.

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In general, a discussion about the executive summary focuses on a complete plan of action which the researcher is going to take to fill the gap in practice regarding care coordination for the elderly who suffer from chronic conditions. Through these steps, the summary proposal the use of the PICOT question application, and evaluating of services and resources, assessing of care coordination and disseminating of the selected nursing diagnosis, all would be made explicit, and further eventual evidence-based nursing practices and better patient outcomes would be achieved. The intervention, developed according to the barriers and promise of care coordination and based on the general approach and standards in practice, requires teamwork, patient focus and technology use to enhance delivery of services. While persistence in quality improvement and incorporating the ideas of stakeholders, healthcare organizations will be able to identify the gaps in the practice and overcome issues in assumptions, benefit from the intelligent suggestions, and use the strategies which will work effectively and fix the problems of the practice. At last, through teamwork and connecting patients, the proposed intervention is aiming to develop a largely all-round care which improves wellbeing of the elderly patients and also boosts health outcomes.


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