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NURS FPX 6614 Assessment 3 Disseminating the Evidence Scholarly Video Media Submission

Student Name Capella University NURS-FPX 6614 Structure and Process in Care Coordination Prof. Name Date Disseminating Evidence: Scholarly Video Media Submission Abstract:  This presentation centers on the dissemination of evidence in nursing, highlighting the importance of sharing knowledge and research within the healthcare community. The study investigates the efficacy of lifestyle modifications compared to antihypertensive medications in overweight adults with hypertension. Through a comprehensive analysis, the presentation argues that lifestyle changes yield more favorable health outcomes in this population. Introduction Dissemination of evidence is a critical nursing component involving the sharing of research and information with fellow healthcare professionals (Chambers, 2018). It encompasses communication of information and resources related to evidence-based interventions (Chambers, 2018). In healthcare, introducing new techniques to a target audience hinges on disseminating evidence-based practices (Purtle et al., 2020). To bridge gaps in evidence-based interventions and address implementation challenges effectively, it is imperative to utilize strategies facilitating the acceptance and integration of evidence-based activities (Purtle et al., 2020). This video presentation aims to disseminate evidence-based approaches related to my intervention and sustain positive outcomes. Care Coordination Efforts The PICOT Question In overweight adults with hypertension, do lifestyle modifications compared to antihypertensive medications result in low blood pressure within 6 months? Brief Introduction to the Issues Obesity is strongly associated with hypertensive symptoms, exacerbating the condition in affected individuals. Studies indicate that obesity is responsible for a significant proportion of primary hypertension cases (Ahmadi et al., 2019). Lifestyle modifications, such as dietary changes and increased physical activity, have been proposed as effective interventions for hypertensive individuals (Ahmadi et al., 2019). Conversely, antihypertensive medications have demonstrated adverse effects within six months of use (Olowofela & Isah, 2018). Therefore, lifestyle changes are recommended over medication (Olowofela & Isah, 2018). Healthcare practitioners play a crucial role in influencing patient behavior by educating them about the benefits of lifestyle changes (Shayesteh et al., 2018). Educational initiatives are essential in raising disease awareness and promoting behavior modification among hypertension patients (Shayesteh et al., 2018). Care Coordination Efforts Care coordination aims to enhance the delivery of healthcare services within and across systems (Kruk et al., 2018). A multidisciplinary healthcare team, consisting of dietitians, nurses, cardiologists, information technologists, and physiotherapists, collaborates in the treatment of hypertensive patients. Team-based care involves patients in their own healthcare decisions, with regular team meetings focused on setting objectives and creating patient-centered goals (Will et al., 2019). The healthcare team employs a holistic approach, with nutritionists providing evidence-based diet plans, physiotherapists offering tailored exercise regimens, cardiologists monitoring patients’ symptoms, and information technologists facilitating telehealth solutions (Nicolai et al., 2018). Implications The adoption of care coordination supports the achievement of the triple aim of health reform, improving patient quality and satisfaction (Kohl et al., 2018). By coordinating patient care and engaging obese hypertensive patients in their treatment, healthcare professionals can foster better health outcomes (Kohl et al., 2018). Change in Practice Related to Services and Resources Resources Healthcare professionals should provide patients with information about the benefits of lifestyle changes through fact sheets, guidelines, social media messages, and handouts (CDC, 2020). Services Care coordinators, including nurses and other medical professionals, should offer support and encouragement to obese hypertensive patients, facilitating their active participation in managing their condition (Hansen et al., 2021). Additionally, healthcare providers can create customized care plans and utilize telehealth for patient education (Hansen et al., 2021). Key Care Coordination Efforts Team-based care is essential for achieving value-based care goals and enhancing the patient experience (Rollet et al., 2021). Multidisciplinary team meetings are instrumental in discussing patient conditions, diagnoses, and treatment plans, ensuring adherence to evidence-based guidelines (Rollet et al., 2021). Efforts to Build Stakeholder Engagement Stakeholder engagement involves identifying, evaluating, organizing, and implementing actions to influence stakeholders (Sperry & Jetter, 2019). A stakeholder engagement plan should consider each stakeholder’s needs and demands (Sperry & Jetter, 2019). Leading the Change in Practice Nurses can apply Kurt Lewin’s change theory to initiate practice changes and engage stakeholders in intervention strategies for obese hypertensive patients (McFarlan et al., 2019). This process involves unfreezing, changing, and refreezing stages to gain stakeholder support, implement changes, and monitor compliance (McFarlan et al., 2019). Encouraging and Building Stakeholder Engagement Organizations should establish a robust stakeholder engagement strategy, beginning with a stakeholder engagement plan that outlines stakeholders’ involvement, approach, and objectives (Boaz et al., 2018). Stakeholders’ needs, interests, and perspectives should be respected throughout the process (Boaz et al., 2018). Future Recommendations Sustaining the Current Outcomes To maintain existing patient outcomes, stakeholders should engage in regular inter-professional coordination through weekly team meetings, facilitating effective communication with patients (Kruk et al., 2018). Enhanced communication fosters trust and rapport, leading to improved health outcomes (Kruk et al., 2018). Healthcare professionals should prioritize patient information confidentiality and approach patient questions with a problem-solving mindset (McFarlan et al., 2019). Recommendations on Moving Forward To enhance care coordination for future patient care initiatives, healthcare providers should consider the following recommendations: Conclusion In conclusion, disseminating evidence in nursing involves sharing knowledge, insights, and research with healthcare professionals. Effective evidence dissemination is crucial for introducing new approaches to specific audiences. This video presentation aims to share knowledge and ideas related to my intervention plan for obese hypertensive individuals. References Ahmadi, S., Sajjadi, H., Nosrati Nejad, F., Ahmadi, N., Karimi, S. E., Yoosefi, M., & Rafiey, H. (2019). Lifestyle modification strategies for controlling hypertension: How are these strategies recommended by physicians in Iran? Medical Journal of the Islamic Republic of Iran, 33, 43. Boaz, A., Hanney, S., Borst, R., O’Shea, A., & Kok, M. (2018). How to engage stakeholders in research: design principles to support improvement. Health Research Policy and Systems, 16(1). CDC. (2020, January 28). Hypertension Resources for Health Professionals | Centers for Disease Control and Prevention. Chambers, C. T. (2018). From evidence to influence. PAIN, 159, S56–S64. Hansen, A. R., McLendon, S. F., & Rochani, H. (2021). Care coordination for rural residents with chronic disease: Predictors of improved outcomes. Public Health Nursing. NURS FPX 6614 Assessment 3 Disseminating the Evidence

NURS FPX 6614 Assessment 2 Enhancing Performance as Collaborators in Care

Student Name Capella University NURS-FPX 6614 Structure and Process in Care Coordination Prof. Name Date Enhancing Performance as Collaborators in Care Presentation Introduction Hello, everyone. I am _________, and I welcome you all to this meeting. Firstly, I would like to acknowledge the presence of our esteemed healthcare professionals in the audience, including nurses, physicians, hospital administrators, nutritionists, physiotherapists, and information technologists. This presentation will focus on the significance of interprofessional collaboration for overweight hypertensive patients. Our multidisciplinary efforts aim to educate these patients about the benefits of adopting a healthier lifestyle. Both lifestyle changes and antihypertensive medications can assist patients with obesity and hypertension. However, research indicates that patients may experience medication side effects within the first six months (Cosimo Marcello et al., 2018). Due to these adverse effects, patients may struggle to adhere to their prescribed medications. Nevertheless, evidence suggests that modifying one’s lifestyle, such as improving diet and engaging in exercise, can lower blood pressure and reduce body weight without adverse effects (Cosimo Marcello et al., 2018). Healthcare providers need to collaborate and develop strategies to educate patients on making healthier lifestyle choices, ultimately helping obese hypertensive patients adopt better habits. Steps to Improve Inter-professional Collaboration Overview to Enhance Evidence-based Practice Each day, new discoveries are made that lead to improved treatments and more efficient care methods for patients. New studies offer better techniques and stronger supporting evidence for patient treatment. Researchers continually uncover information that can aid healthcare providers in delivering the best possible care (O’Cathain et al., 2019). The organization should initiate training in relevant areas to enhance evidence-based practice among healthcare professionals. Allowing ample time for healthcare staff to review and implement research findings is also beneficial. Professionals with expertise in evidence-based approaches can serve as mentors and educators for their colleagues (Lafuente et al., 2019). Healthcare leaders should also facilitate access to resources that support the pursuit of evidence-based literature and provide necessary support. This approach to improving evidence-based practices will also enhance inter-professional collaboration in a healthcare setting (Lafuente et al., 2019). Explanation of the Planning Stages To promote evidence-based practices and enhance inter-professional collaboration, the following steps can be taken: Forming inter-professional teams: Creating inter-professional teams that include nurses, physicians, nutritionists, physiotherapists, hospital administrators, and IT specialists is essential for enhancing collaboration (Frank et al., 2020). Appointing team leaders: Designated leaders will employ strategies supported by robust data. Leaders will also assess whether there is sufficient information to justify a new approach. Data collection will continue so that leaders can evaluate progress and make necessary adjustments (Frank et al., 2020). Regular team meetings: Regular team meetings, led by designated team leaders, will be held to establish goals based on patient needs. Healthcare workers can express their views and preferences in these team meetings, improving interprofessional collaboration. These meetings will facilitate the adoption of innovative strategies to enhance health outcomes, reduce costs, and minimize errors (Frank et al., 2020). Educational Services and Resources Educational Methodologies Leveraging Health Information Technology (HIT): Healthcare information technology, such as telehealth, can be utilized by nurses and other team members (Chike-Harris et al., 2021). Telehealth allows healthcare professionals to educate patients about healthier lifestyle choices and monitor their adherence to new healthy habits. Identifying the patient’s preferred learning method: Patients have varying learning styles; therefore, it is essential to determine whether they would benefit more from telehealth or printed materials (Chike-Harris et al., 2021). NURS FPX 6614 Assessment 2 Enhancing Performance as Collaborators in Care Tailoring education to the patient’s interests: Patients should recognize the importance of being educated on healthy lifestyle choices. Creating a comfortable environment by engaging the patient in conversation is crucial. While some patients may benefit from in-depth knowledge of their condition, others may prefer a concise checklist covering the essentials (Yen and Leasure, 2019). Consideration of the patient’s abilities and limitations: Identifying any cognitive, emotional, or motor deficits that may hinder the patient’s ability to learn is critical. If a patient has difficulty hearing, visual aids and hands-on approaches may be more effective than verbal explanations (Yen and Leasure, 2019). Collaborate and Partner with Inter-professional Team Members Implementation Process Lee and Bae (2018) assert that the Chronic Care Model (CCM) can facilitate improved care coordination. The CCM model assists healthcare professionals in formulating a treatment strategy after conducting comprehensive assessments of patients’ conditions. Patients and physicians can work more effectively to pinpoint issues and find solutions. With the assistance of CCM, healthcare providers and patients can collaboratively set and achieve support goals (Lee and Bae, 2018). The care coordination team should include the patient and their family, the primary care provider, the care coordinator, nutritionists, physiotherapists, and the peer psychologist. These team members should fulfill their respective treatment responsibilities and further provide intervention and follow-up monitoring duties. The most crucial step in managing hypertensive symptoms is to establish a team that delivers comprehensive care tailored to the needs of obese patients with a sense of responsibility (Lee and Bae, 2018). The next step is to design quality management processes and monitor activities. After educating patients, monitoring ongoing operations and evaluating their quality will be essential. Plans to Collaborate and Partner To facilitate collaboration among team members, I will initially establish a social platform for communication among professionals from various disciplines. Weekly team meetings, brainstorming sessions, or clusters will provide a forum for staff to discuss patients and develop plans for delivering optimal care (Moser et al., 2018). Additionally, we can enhance communication and information sharing by integrating collaboration into routine activities. Consistent staff collaboration is an effective means of fostering a cooperative atmosphere (Schmutz et al., 2019). Therefore, I will implement processes to ensure that all healthcare workers regularly collaborate to achieve their goals. Increased workforce unity, morale, and productivity can result from enhanced face-to-face and virtual information exchange opportunities. Implementing a HIPAA-compliant text messaging platform could facilitate effective staff collaboration (Ganapathy et al., 2020). Outcomes of the New Process Results Assessments The OECD has established six criteria for assessing a strategy:

NURS FPX 6614 Assessment 1 Defining a Gap in Practice

Student Name Capella University NURS-FPX 6614 Structure and Process in Care Coordination Prof. Name Date Proposing Evidence-Based Change Clinical Priorities and Information Gaps for the Elderly Elderly patients (65+) in urban healthcare settings with multiple chronic conditions require a holistic, person-centered approach. This means understanding their comprehensive needs, from medical to psychosocial. Seamless transitions between in-patient and home care are essential to prevent health complications and readmissions. Given their complex medication regimes, proper medication management and adherence are vital. Educating patients and caregivers enhances at-home care and eases the healthcare system’s burden (Vareta et al., 2022). However, there are challenges. A significant hurdle is the inconsistency in electronic health records (EHR). Accurate, up-to-date EHRs are pivotal for effective care coordination. Further, communication gaps between primary and specialty care providers can lead to inefficient care, like redundant testing or conflicting treatments. Additionally, not adequately addressing the patient’s socioeconomic context can negatively impact health outcomes (Fjellså et al., 2022). Addressing these barriers is crucial for improved care coordination for this group. PICOT Question Related to Care Coordination Gap The proposed PICOT question – “In elderly patients with multiple chronic conditions in urban healthcare settings (P), how does implementing a coordinated interprofessional care plan (I) compared to standard care without active coordination (C) influence the number of hospital readmissions (O) over 6 months (T)?” – stems from evident gaps in current care models. Studies have consistently shown that fragmented care, often typical of the standard model, correlates with increased hospital readmission rates, decreased patient satisfaction, and an uptick in preventable complications for the elderly. For instance, a study found that elderly patients with uncoordinated care had a 50% higher chance of being readmitted to the hospital within 30 days of discharge (Hovsepian et al., 2023). Another study highlighted that lack of care coordination for elderly patients led to increased hospital stays and escalated healthcare costs by approximately 30% (Wolff et al., 2023). Thus, a care coordination approach is considered beneficial for the concerned population.  Evaluation of Potential Services and Resources for Care Coordination Elderly patients with multiple chronic conditions in urban settings require specialized care services and resources, such as geriatric assessment units, which provide in-depth evaluations of medical, psychosocial, and functional health insights. Comprising a team of diverse specialists, these units yield a comprehensive grasp of patients’ health needs. Furthermore, home care services, from daily assistance to specialized nursing care, are vital for these patients, ensuring their independence (Liu et al., 2023). Telehealth consultations, enabled by technology, have also emerged as a beneficial tool, especially for those facing mobility challenges. However, several barriers hinder optimal care coordination. Service fragmentation remains a significant challenge, often leading to miscommunications and inefficiencies. Limited health literacy complicates their understanding of health information and optimal care paths. Financial constraints also pose a considerable barrier; despite insurance, the costs associated with various services can be prohibitive (Arain et al., 2022). It’s essential to employ a patient-focused approach, leveraging scholarly insights to refine care coordination, ensuring accessibility and effectiveness in serving this vulnerable demographic. Optimal Care Coordination Intervention To enhance evidence-based practice for elderly patients in urban healthcare settings, an Interprofessional Collaborative Care Team (ICCT) is suggested. The ICCT, including physicians, nurses, pharmacists, social workers, and patient navigators, would ensure comprehensive care coordination (Gao et al., 2023). Key responsibilities of this team would encompass consistent patient evaluations, formulating and revising individualized care plans, enlightening patients and caregivers through dedicated educational sessions, and ensuring medication reconciliation to prevent potential drug-drug interactions and bolster medication compliance. By integrating these multifaceted professionals, the intervention addresses the intricate needs of the population in a streamlined and effective manner. Nursing Diagnosis and Collaborative Care Approach The primary nursing diagnosis pinpointed is the risk for ineffective health management. This risk stems from the multifaceted nature of the health issues experienced by elderly patients and the tendency for healthcare services to be fragmented, potentially causing care gaps. Regular nursing-led educational sessions will be initiated to counteract this risk, focused on enhancing patient and caregiver understanding of health conditions and treatment modalities. Furthermore, prioritizing collaborative care meetings that incorporate the voices of patients, caregivers, and the entire healthcare team can ensure cohesive care planning and delivery. Additionally, the optimal utilization of Electronic Health Records (EHR) is a cornerstone strategy. It ensures that all care team members have real-time access to patient data, fostering effective communication and coordination (Innab, 2022). Structuring the Intervention and Anticipating Outcomes The initial phase entails the recruitment and meticulous training of dedicated ICCT members. Subsequently, clear protocols for routine patient assessments and evaluations will be developed and institutionalized. A robust system that facilitates seamless communication and ensures consistent EHR updates will also be implemented (Strachna et al., 2022). Through these interventions, several measurable outcomes are projected. There’s an anticipation of a marked reduction in hospital readmissions by approximately 25% over six months. Concurrently, feedback mechanisms like patient satisfaction surveys should reflect improved scores, particularly in areas of care coordination. A pivotal metric would be observing a pronounced increase in medication compliance among our target population. This approach is predicated on several assumptions, such as unwavering commitment and active participation of all ICCT members, sustained resource allocation and support from the overarching healthcare entity, and proactive engagement from patients and their caregivers throughout the care continuum. As this care coordination model is operationalized, it’s imperative to maintain a feedback loop for regular assessment of the process, continuous professional development, and invaluable insights to drive iterative refinements in the care process. References Arain, S., Al Shakori, M., Thorakkattil, S. A., Mohiuddin, S. I., & Al-Ghamdi, F. (2022). Implementation of pharmacist-led telepsychiatry services: Challenges and opportunities in the midst of COVID-19. Journal of Technology in Behavioral Science, 7, 468–476.  Fjellså, H. M. H., Husebø, A. M. L., & Storm, M. (2022). eHealth in care coordination for older adults living at home: Scoping review. Journal of Medical Internet Research, 24(10), e39584.  Gao, H., Yous, M.-L., Connelly, D., Hung, L., Garnett, A., Hay, M., &