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NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Student Name Capella University NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Patient Discharge Care Planning This assessment concentrates on formulating discharge care plans for Marta Rodriguez, recently hospitalized due to a severe accident en route to college. Following a four-week trauma center stay involving multiple surgeries and antibiotic treatment, ensuring coordinated care for Marta is imperative. In my role as the senior care coordinator, I will present Marta’s case in an upcoming interdisciplinary team meeting to deliberate on her discharge plans. Longitudinal, Patient-Centered Care Plan To guarantee Marta Rodriguez receives comprehensive, patient-centered care, the interdisciplinary team will integrate Health Information Technology (HIT) components to enhance communication and coordination throughout her care journey. These HIT elements include electronic health records (EHRs), secure messaging platforms, telehealth technology, and medication reconciliation tools. EHRs will facilitate real-time access and updates to Marta’s medical records, facilitating the development of a comprehensive care plan (Schwab et al., 2021). Secure messaging platforms will streamline communication among team members, especially regarding changes in Marta’s condition, appointments, and medication schedules (Flickinger et al., 2022). Telehealth technology will allow remote monitoring of Marta’s vital signs, enabling early intervention (Chowdhury et al., 2020). Additionally, medication reconciliation tools will ensure the accuracy of her medication list, thereby reducing medication errors. NURS FPX 6612 Assessment 3 Patient Discharge Care Planning To prevent Marta’s readmission within 48 hours after discharge, the inter-professional team must ensure Marta receives adequate education, support, and follow-up care (Oksholm et al., 2023). The use of HIT elements can reinforce these efforts. For example, telehealth technology can monitor Marta’s post-discharge progress, provide virtual support, and identify potential issues that might lead to readmission. Furthermore, secure messaging platforms can offer Marta timely and accurate information regarding her medication and follow-up appointments. Simultaneously, incorporating these HIT elements will promote care coordination for Marta by fostering communication and collaboration among team members. Access to uniform information about Marta will enable the development of a comprehensive care plan. Furthermore, EHRs will allow team members to track Marta’s progress, ensuring she receives appropriate care throughout her recovery. By harnessing HIT elements, the inter-professional team can deliver a patient-centered, coordinated, and effective care plan tailored to Marta’s unique needs. Data Reporting Data reporting holds immense significance in the healthcare industry, shaping care coordination, administration, clinical efficiency, and interdisciplinary innovation in treatment. In Marta Rodriguez’s case, data reporting pertaining to her behaviors can enhance the quality of her care and support her recovery in three key ways: Care Coordination: Data reporting can facilitate care coordination among inter-professional team members by providing a shared understanding of Marta’s condition and progress (Brooks et al., 2020). For instance, data on Marta’s medication adherence, vital signs, and symptoms can be reported through EHRs or secure messaging platforms, enabling effective collaboration in her care management and reducing the risk of complications or readmissions. Care Management: Data reporting can shape care management by identifying areas where Marta may require additional support or interventions. Information on her pain levels, mobility, and nutritional status, for example, can be reported to the team, allowing them to adjust her care plan as needed to improve its quality and enhance her recovery. Inter-professional Innovation: Data reporting can drive innovation in inter-professional care by providing insights into Marta’s behaviors and preferences. Data regarding her language preferences or cultural background can be shared with the team, enabling them to tailor their care to her specific needs, thereby promoting patient-centered care and better outcomes. To ensure data quality, the team should implement data validation protocols, conduct regular audits, and provide training on data entry and reporting best practices. Additionally, the data must be relevant to Marta’s care goals and aligned with evidence-based practices, allowing the team to make informed decisions and provide her with the best possible care. Client’s Record Influencing Health Outcomes Patient records play a pivotal role in improving health outcomes. Marta Rodriguez’s case demonstrates how interprofessional teams can leverage Health Information Technology (HIT) to collect, analyze, and share information from client records, ultimately enhancing patient care and outcomes. This discussion explores how data obtained from patient records can positively influence health outcomes and how interprofessional teams can coordinate their efforts using HIT. HIT enables interprofessional teams to gather and analyze data from client records, offering insights into trends, patterns, and care gaps (Leslie & Paradis, 2018). For instance, Marta’s records can provide valuable information about her medical history, medication regimen, and health status, facilitating the development of a comprehensive care plan tailored to her unique needs. HIT can also help identify potential risks, such as adverse drug reactions or postoperative complications, enabling prompt intervention to prevent negative health outcomes. Moreover, HIT enhances care coordination among interprofessional team members. By sharing information from client records, team members can collaborate more effectively in managing patient care. Tools like EHRs and secure messaging platforms enable real-time communication, ensuring that all team members are up-to-date with the latest patient information. This reduces the risk of miscommunication and errors, ultimately leading to improved health outcomes for the patient. NURS FPX 6612 Assessment 3 Patient Discharge Care Planning Effective coordination of findings among interprofessional team members requires clear communication, a shared care plan, and a willingness to collaborate towards common goals (Rawlinson et al., 2021). HIT tools provide a centralized platform for accessing and sharing information, ensuring that all team members have a comprehensive understanding of the patient’s care needs. This collaborative approach enables the provision of holistic care that addresses all aspects of the patient’s health, resulting in better health outcomes. Positive health outcomes can be influenced by the use of HIT to collect, analyze, and distribute data from patient records. Interprofessional teams can utilize HIT tools to coordinate their efforts, ensuring access to the latest patient information. Through effective collaboration and the proficient use of HIT tools, these teams can provide patient-centered care that comprehensively addresses all aspects of the patient’s health, leading to improved health outcomes. Conclusion Marta Rodriguez’s post-discharge care involves a patient-centered approach

NURS FPX 6612 Assessment 2 Quality Improvement Proposal

Student Name Capella University NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Quality Improvement Proposal In the pursuit of delivering high-quality healthcare and enhancing patient safety, healthcare organizations should aspire to qualify as Accountable Care Organizations (ACOs). This designation instills greater patient confidence in managing their health needs, reducing hospital costs, and providing superior healthcare solutions. Evidence-based approaches, such as care plans, have proven effective in enhancing patient outcomes and reducing expenses. ACOs are ideally positioned to leverage care plans in managing the complex healthcare requirements of patients (Fraze et al., 2020). ACOs have demonstrated success in delivering quality healthcare to patients with depression, effectively reducing preventable hospitalizations. A comparison between ACO and non-ACO hospitals reveals significantly lower rates of preventable hospitalizations in ACO-affiliated healthcare settings (Barath et al., 2020). The establishment of coordinated medical care for the broader community and population has led to improved quality and safety outcomes for patients within ACOs. Accountable Care Organizations are specifically designed to address the cost and quality of healthcare services provided to patients. In ACO healthcare settings, all stakeholders share responsibility for delivering affordable care while minimizing waste (Moy et al., 2020). This assessment recommends expanding an organization’s Health Information Technology (HIT) to incorporate quality metrics. It delineates the primary focus of information gathering and how it contributes to guiding organizational practice. Additionally, it identifies potential challenges that may arise within data-gathering systems. Recommendations for Expanding HIT Health Information Technology (HIT) is essential for delivering high-quality, cost-effective healthcare. HIT enhances access to data, streamlines information retrieval, and provides healthcare practitioners and caregivers with comprehensive insights into patients’ complex health needs through data analytics. Each patient’s health records are meticulously managed via a unique Medical Registration Number (MRN). Electronic folders, containing detailed examinations and prescribed medications, are accessible to all healthcare staff, including doctors, paramedics, and nurses, enabling better healthcare planning and improved patient outcomes at reduced hospitalization costs. To ensure that healthcare organizations meet the healthcare needs of their patients, HIT should be expanded comprehensively across all facets of healthcare settings. A user-friendly and accessible system should be designed to facilitate timely patient care. Patients can access their health charts and detailed examinations via mobile applications, while healthcare staff can access patient portfolios through hospital site computers, with remote access available via hospital databases. For instance, consider a case like that of Caroline McGlade, a 61-year-old woman whose Electronic Health Record (EHR) contains information about her medical history, laboratory examinations, and a potential breast cancer diagnosis. Health information technologies play a pivotal role in effectively managing and providing nursing care, ultimately contributing to the desired quality improvement in patient outcomes (Alaei et al., 2019). Focus on Information Gathering and Guiding Organizational Development The primary objective of information gathering is to deliver high-quality healthcare to patients at reduced costs while addressing complex healthcare needs. Data collection, informatics, and analytics enable caregivers to plan more effectively, eliminating redundancies in hospital databases. Organizations have evolved through the progressive implementation of database-driven changes. A robust and dedicated health system now serves every individual, resulting in significantly improved patient outcomes and employee efficiency. Healthcare staff have gained greater control over their achievements and performance, with access to performance charts and projected growth. Employees can provide feedback on their job satisfaction levels and make inquiries during work hours. While monitoring and managing healthcare databases present challenges, their effectiveness is crucial for organizational development within ACO hospitals. Artificial Intelligence and advanced information and communication technologies hold the potential to provide better solutions for healthcare, particularly in nursing informatics (Robert, 2019). Problems with Data Gathering Systems Data gathering is a complex task, and its management and handling are equally demanding. The problems associated with data gathering systems can be addressed through a three-step process: data gathering, preprocessing of relevant data, and data analysis. Firstly, healthcare staff must receive comprehensive training in using digital health databases to prevent complications in patient data collection and management. The information required should be explicitly defined, and healthcare staff should be well-versed in essential healthcare tools. Adequate training and guidance should be provided to healthcare staff. Ensuring data security and controlled access is vital to safeguard patients’ sensitive data. Stringent information security protocols must be implemented to prevent any unauthorized access or breaches of patient data. NURS FPX 6612 Assessment 2 Quality Improvement Proposal Efforts should be made to establish a secure data protection system with strong management support. Dedicated resources should be allocated to data security, ensuring that sensitive patient information is accessible only to authorized healthcare staff. The challenge of handling and storing continuously expanding data can be addressed through the implementation of cloud-based data storage strategies. It is imperative for healthcare organizations to acknowledge and address the stress and burnout experienced by physicians and other healthcare staff in their daily use of health information technologies (HIT) (Gardner et al., 2018). Conclusion In summary, the central role of health information technology (HIT) in the development of Accountable Care Organizations cannot be overstated. HIT implementation is essential for leveraging new and innovative information and communication technologies effectively. Coordinated data gathering, supported by unique MRNs for individual patients, addresses complex health needs. Challenges in data gathering systems can be resolved through formal training, enhanced data security, and effective data storage solutions. By overcoming these challenges, healthcare organizations can deliver high-quality healthcare at reduced costs. References Alaei, S., Valinejadi, A., Deimazar, G., Zarein, S., Abbasy, Z., & Alirezaei, F. (2019). Use of health information technology in patients care management: A mixed methods study in Iran. Acta Informatica Medica, 27(5), 311. https://doi.org/10.5455/aim.2019.27.311-317 Barath, D., Amaize, A., & Chen, J. (2020). Accountable care organizations and preventable hospitalizations among patients with depression. American Journal of Preventive Medicine, 59(1), e1–e10. https://doi.org/10.1016/j.amepre.2020.01.028 Fraze, T. K., Beidler, L. B., Briggs, A. D. M., & Colla, C. H. (2020). Translating evidence into practice: ACOs’ use of care plans for patients with complex health needs. Journal of General Internal Medicine, 36(1), 147–153. https://doi.org/10.1007/s11606-020-06122-4 Gardner, R. L., Cooper, E., Haskell, J., Harris, D. A., Poplau,

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

Student Name Capella University NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Triple Aim Outcome Measures Introduction I am ________, the case manager at Sacred Heart, a rural hospital. This presentation aims to guide hospital members in achieving care coordination through the Triple Aim process. Purpose This presentation aims to enlighten Sacred Heart Hospital’s leadership on care coordination, aligning practices with Triple Aim objectives for the rural population. It also seeks to enhance understanding of supporting models for Triple Aim, focusing on the Patient-Centered Medical Home (PCMH) and Transitional Care. Triple Aim The Triple Aim focuses on improving healthcare quality with objectives centered on enhancing patient experience, healthier populations, and lower healthcare costs. This presentation details how the Triple Aim contributes to community health, patient care experience, and cost reduction. Patient Experience of Care Triple Aim prioritizes improving patient experience by reducing waiting times, improving communication, and involving patients in treatment plans. Patient satisfaction positively impacts adherence to treatment, engagement in care, and overall health outcomes. Enhancing Community or Population Health The Triple Aim aims to improve community health by recognizing and addressing health needs. Care coordination is crucial in identifying high-risk patients and ensuring they receive appropriate care. Collaboration with community partners for preventive measures is essential. Reducing Per Capita Costs Efficient care coordination contributes to reducing healthcare costs by minimizing waste, unnecessary procedures, and preventing readmissions. Collaboration with community partners and preventive care further decreases healthcare costs. In conclusion, achieving Triple Aim objectives requires healthcare providers to enhance patient experience, community health, and minimize healthcare costs. Effective care coordination plays a critical role in achieving these goals. Analyzing the Relationship Between Health Models and Triple Aim The PCMH and Transitional Care models align with Triple Aim objectives, focusing on patient-centered care, improving population health, and reducing healthcare costs. These models show potential in enhancing patient outcomes and care coordination. Structure of Healthcare Models PCMH and Transitional Care models enhance care quality through a team-based approach, emphasizing comprehensive and coordinated care. They rely on electronic health records, evidence-based guidelines, and interdisciplinary teams to ensure appropriate care. Evidence-based Data Shaping the Care Coordination Process Care coordination in nursing relies on evidence-based data to identify patient needs, barriers to care, and develop tailored interventions. This data-driven approach improves patient outcomes, promotes continuity of care, and reduces the risk of medical errors. Governmental Regulatory Initiatives To achieve Triple Aim, Sacred Heart Hospital can incorporate regulatory initiatives like the Medicare Shared Savings Program (MSSP) and the Hospital Readmissions Reduction Program (HRRP). These programs incentivize care coordination, improve quality, and reduce healthcare costs. Process Improvement Recommendations to Stakeholders Stakeholders, including hospital administration, healthcare providers, patients, caregivers, and Vila Health representatives, should be informed about the need to update the care coordination process. Addressing questions about resources and timeline concerns will ensure successful implementation. References 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 NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures 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 NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures 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