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NURS FPX 6616 Assessment 3 Assessing the Best Candidate for the Role

Student Name Capella University NURS-FPX 6616 Ethical and Legal Considerations in Care Coordination Prof. Name Date Assessing the Best Candidate for the Role: A Toolkit for Success The Care Coordinator position serves a pivotal role in enhancing healthcare outcomes for the community of Appalachian Kentucky. This community, with its unique cultural norms and socioeconomic conditions, presents various challenges that directly impact healthcare delivery and patient outcomes. Given the region’s high rates of heart disease and diabetes, effective care coordination is crucial. Through advocacy, collaboration, and strategic use of data, the Care Coordinator is instrumental in bridging the healthcare gaps and ensuring improved health outcomes for the community. This role aligns with evidence-based practices that emphasize holistic, patient-centric care, and continuous care plan improvement. Job Description: Care Coordinator The Care Coordinator role in Appalachian Kentucky entails comprehensive care delivery with a focus on prevalent conditions like heart disease and diabetes, according to the region’s high disease incidences (CDC, 2022). In collaboration with the healthcare team, the Care Coordinator develops, implements, and monitors care plans, factoring in the community’s unique cultural norms and socioeconomic circumstances, which aligns with the Chronic Care Model (Tanumihardjo et al., 2023). The Care Coordinator bridges the gap between patients and healthcare services, addressing barriers such as access to specialized services, transportation, income disparities, and health insurance. This advocacy aligns with the American Nurses Association’s Code of Ethics (ARC, 2020; Doe, 2022). In healthcare delivery, legal, ethical, and cultural competence, including the protection of patients’ rights and respect for the community’s cultural nuances, is upheld. Lastly, data usage to track patient outcomes, adapt care plans, and evaluate care coordination effectiveness, is a recommended practice by the Health Information and Management Systems Society. This approach seeks to optimize health outcomes in the community. Interview Questions Ethical Practices and Care Coordination The ideal candidate should deeply comprehend and adhere to ethical practices such as respecting patient autonomy, promoting well-being (beneficence), preventing harm (non-maleficence), and ensuring fair care (justice) (Cheraghi et al., 2023). Given Appalachian Kentucky’s socioeconomic challenges, the candidate should exhibit an unwavering commitment to patient advocacy, prioritizing patient welfare and, respect for cultural norms. They should also address health-related challenges unique to the community. This approach aligns with the American Nurses Association’s (ANA) Code of Ethics which emphasizes patient advocacy and respect for cultural diversity (Doe, 2022). Legal Knowledge and Policy Awareness in Care Coordination Knowledge of laws like HIPAA and policies like Medicare and Medicaid regulations is crucial for the ideal candidate. Additionally, they should have a keen understanding of state-specific laws or programs that enhance healthcare accessibility and affordability, specifically in low-income, rural regions such as Appalachian Kentucky (ARC, 2020). The candidate’s capacity to interpret and apply these regulations effectively is vital for ensuring lawful, efficient, and accessible healthcare delivery in this community. Stakeholder Collaboration and Interprofessional Team Dynamics The candidate should have the aptitude for productive collaboration with stakeholders such as healthcare providers, patients, family members, insurance providers, and social care workers. In the context of Appalachian Kentucky’s close-knit community, they should successfully integrate within these social structures, aiming for optimal healthcare outcomes. This aligns with the World Health Organization’s emphasis on interprofessional collaboration in achieving universal health coverage (Seaton et al., 2020). Data Utilization for Care Enhancement The prospective candidate must possess strong capabilities in data collection, analysis, and interpretation to refine healthcare delivery. This includes employing data to illuminate health disparities and optimize health outcomes in the context of prevalent diseases and comorbidities in Appalachian Kentucky. This expectation mirrors the stance of the Health Information and Management Systems Society (HIMSS) on the essential role of data in enhancing healthcare (Haendel & Abdelhak, 2022). Such data-driven insights will be instrumental in devising effective health strategies and interventions for the community. References Appalachian Regional Commission. (2020).  Investing in Appalachia’s economic future. https://www.arc.gov/  Centers for Disease Control and Prevention. (2022). National Diabetes Statistics. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf  Cheraghi, R., Valizadeh, L., Zamanzadeh, V., Hassankhani, H., & Jafarzadeh, A. (2023). Clarification of ethical principle of the beneficence in nursing care: An integrative review. BMC Nursing, 22(1). https://doi.org/10.1186/s12912-023-01246-4  NURS FPX 6616 Assessment 3 Assessing the Best Candidate for the Role Doe, M. J. (2022). Nursing ethics embedded in nursing theoretical frameworks. Nursing Science Quarterly, 35(2), 270–272. https://doi.org/10.1177/08943184211070579  Haendel, A., & Abdelhak, M. (2022). Practice and legal issues: Clinical documentation, data ownership, access, and patient rights. Health Informatics, 453–464. https://doi.org/10.1007/978-3-030-91237-6_30  Seaton, J., Jones, A., Johnston, C., & Francis, K. (2020). Allied health professionals’ perceptions of interprofessional collaboration in primary health care: An integrative review. Journal of Interprofessional Care, 35(2), 1–12. https://doi.org/10.1080/13561820.2020.1732311  Tanumihardjo, J. P., Kuther, S., Wan, W., Gunter, K. E., McGrath, K., O’Neal, Y., Wilkinson, C., Zhu, M., Packer, C., Petersen, V., & Chin, M. H. (2023). New frontiers in diabetes care: Quality improvement study of a population health team in rural critical access hospitals. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-022-07928-0  NURS FPX 6616 Assessment 3 Assessing the Best Candidate for the Role

NURS FPX 6616 Assessment 2 Summary Report on Rural Health Care And Affordable Solutions

Student Name Capella University NURS-FPX 6616 Ethical and Legal Considerations in Care Coordination Prof. Name Date Summary – Rural Community Identification and Description Appalachian Kentucky has been chosen as the community, for this report. It consists of 54 counties situated in the Appalachian Region of the United States. This region is known for its isolation, economic difficulties, and distinct cultural characteristics that directly impact healthcare accessibility and outcomes for its residents. In Appalachian Kentucky, poverty and unemployment rates are significantly high with 25.4% of the population living below the poverty line compared to the average of 10.5% (ARC, 2020). The primary health challenges faced by this community revolve around diseases like heart disease and diabetes. The prevalence of diabetes in 2019 was notably higher at 14.1% compared to the average of 9.4% (CDC, 2020). The focus of this care plan is on the population who often deal with comorbidities simultaneously. These individuals encounter obstacles such as access to specialized healthcare services, inadequate transportation options, low-income levels, and a lack of health insurance. All factors complicate effective management of their health conditions (Hash et al., 2023).In this culturally diverse community, the care coordinator must be aware of the specific norms and values, such as a strong inclination towards self-reliance and close-knit community relationships. These cultural aspects can significantly impact health-seeking behavior and adherence to care plans. In addition to this, socioeconomic factors influencing health behaviors must be taken into account. High rates of illiteracy, unemployment, and poverty often lead to unhealthy lifestyle choices and barriers to accessing and utilizing healthcare resources.  Interprofessional Team and Telehealth Assistance The interprofessional team in the Appalachian Kentucky community primarily consists of primary care physicians, nurse practitioners, community health workers, and pharmacists. These health professionals play critical roles in providing care to the rural populace; however, their services are often stretched thin due to the high patient-to-provider ratio, with only 68 primary care physicians per 100,000 populations in Kentucky’s rural areas compared to the national average of 80 (Folken, 2022). Moreover, the scarcity of specialist healthcare providers in the area creates a significant gap in healthcare provision, especially for the elderly population suffering from multiple chronic diseases. When it comes to resources the community also has local clinics dedicated to healthcare, food banks that provide nourishment organizations focused on housing and religious institutions. These establishments play a role, in areas offering essential health services, nutrition assistance, housing support, and social connections. Moreover, they hold a level of trust and cultural ties within the community making them valuable assets, for any healthcare endeavor. NURS FPX 6616 Assessment 2 Summary Report on Rural Health Care And Affordable Solutions The introduction of telehealth has the potential to significantly mitigate these challenges by linking local health providers with a broader network of healthcare professionals, including cardiologists, endocrinologists, mental health professionals, dietitians, and geriatricians. These telehealth partners can provide specialist consultations, assist in patient monitoring, and provide guidance on complex case management, thus enhancing the quality of care provided to the rural community. Additionally, telehealth can facilitate the capacity-building of local providers through online training, mentorship, and case discussions (Cushing, 2022). One way to make the most of community resources is, by teaming up with clinics, for virtual healthcare consultations. Additionally, we can utilize community spaces to hold sessions and work together with food banks to tackle needs. Religious institutions have a role to play in promoting health initiatives and bridging gaps when it comes to accessing healthcare. Other crucial stakeholders that can support this healthcare initiative include local community organizations, nonprofits focused on rural health, and local and state government bodies. These stakeholders can assist in mobilizing resources, advocating for health policy changes, and providing necessary infrastructure support for implementing telehealth services. For instance, government bodies can ensure the provision of high-speed internet facilities, which are vital for the effective operation of telehealth services. Cultural Competence and Care Coordination Understanding the cultural fabric of the Appalachian Kentucky community is critical to providing effective and culturally competent healthcare. Appalachian culture, deeply rooted in self-reliance, familial bonds, and community support, directly influence the health behavior patterns of its residents. The healthcare providers must therefore acknowledge these cultural nuances and adapt their healthcare delivery approaches accordingly. For instance, since the residents of this area value familial ties and community involvement, healthcare providers must consider involving family members and community health workers in patient care plans (Collett et al., 2022). Applying cultural competence within the interprofessional team is not only about understanding the culture of the community but also about learning how to work together in a way that respects and utilizes each member’s unique skills and perspectives. This cultural competence within the team promotes better communication, improved problem-solving, and more efficient care coordination. Furthermore, culturally competent care coordination can also have a positive impact on health outcomes by promoting patient engagement, improving patient satisfaction, and enhancing adherence to care plans. For example, in a region like Appalachian where community relationships are strong, coordinating care that involves local community health workers and family members can enhance the trust and acceptance of care plans among patients (Hash et al., 2023).  Technology-Based Outreach Strategies The use of technology in healthcare delivery can significantly improve healthcare accessibility and outcomes for the Appalachian Kentucky community, particularly the elderly population suffering from chronic diseases. One practical approach that can yield results is the utilization of Remote Patient Monitoring (RPM). This innovative technology enables the monitoring of patient’s vital signs aiding in the detection and management of potential health complications particularly for individuals, with conditions like diabetes and heart disease. A recent study conducted by Shaik et al. (2023) revealed that RPM has the potential to reduce hospitalizations by 25% and emergency department visits by 19% among patients with diseases. Another beneficial strategy worth considering is the implementation of virtual group consultations and educational sessions. These virtual gatherings offer patients peer support, shared learning experiences, and convenient access to healthcare professionals without requiring them to travel. Such an approach

NURS FPX 6616 Assessment 1 Community Resources and Best Practices

Student Name Capella University NURS-FPX 6616 Ethical and Legal Considerations in Care Coordination Prof. Name Date Slide 1: Community Resources and Best Practices Welcome esteemed leaders. Today, we delve into a pressing issue that has been confronting our healthcare organization – high readmission rates. This deep dive will include a thorough review of our current practices, a dissection of the legal and ethical implications of these readmission rates, and a proposal for a potential solution through an evidence-based intervention known as the “Transitional Care Model”. Our goal is not just to highlight the challenges but also to explore collaborative strategies to enhance the quality of care, improve patient outcomes, and uphold our ethical responsibilities while minimizing legal risks. Thank you for embarking on this crucial journey of innovation and improvement with us. Slide 2: Purpose of the Presentation The purpose of this presentation is to comprehensively examine and address the pressing issue of high readmission rates within our healthcare organization. Through this presentation, we aim to illuminate the severity and implications of this problem, including its legal and ethical ramifications. Moreover, we will introduce an evidence-based intervention strategy – the “Transitional Care Model” – that has the potential to significantly improve these outcomes. This presentation will serve as a collaborative platform to discuss and devise actionable strategies that can enhance the quality of our healthcare services, improve patient outcomes, reduce readmission rates, and thereby fulfill our legal and ethical responsibilities more effectively. We strive for this dialogue to lead us to a pathway that ensures the best possible care for our patients and a stronger, more efficient, and more ethically sound healthcare organization. Slide 3: Description of the Current Situation and Issues In the past year, our hospital discharged 10,000 patients, of which 2,000, or 20%, have been readmitted within 30 days. A closer look at the data reveals a high readmission rate among patients with chronic conditions, particularly heart disease and diabetes, which constitute 50% of our total readmissions. Specifically, heart disease patients show a readmission rate of 35%, while for those with diabetes, the rate stands at 30%. This readmission trend indicates potential inefficiencies in the care delivery system and post-discharge procedures, as each readmission points to a distressing return to the hospital for the patients and their families (Zumbrunn et al., 2022). The use of healthcare information systems (HCIS) in care coordination presents various ethical issues. One of the most significant issues is the potential violation of patient privacy. Although HCIS are designed to be secure, the risk of breaches, whether unintentional or through cyber-attacks, is a pressing concern. Healthcare data is highly sensitive, and any violation could result in severe emotional, social, and even financial harm to the patients. Furthermore, the ethical issue of informed consent arises, particularly in relation to how and when patients’ data is used or shared. Although systems often require patients to sign broad consent forms for the use of their information, there are debates about the extent to which patients fully understand the implications of this consent  (Wright et al., 2023). NURS FPX 6616 Assessment 1 Community Resources and Best Practices Moreover, health inequities may also be amplified with the use of HCIS. These systems are more likely to benefit patients who are literate, have access to technology, and possess the ability to manage their health information online. This could potentially marginalize certain patient populations, such as the elderly, low-income individuals, and those living in remote areas, which raises questions about the ethical principles of justice and equality (Zumbrunn et al., 2022). Lastly, the reliance on algorithmic decision-making tools within these systems also presents ethical issues. While these tools can assist in diagnosis and treatment decisions, they may inadvertently introduce bias, reducing the individualized care each patient should receive  (Wright et al., 2023). The ultimate challenge is to find a balance that allows the utilization of HCIS to improve care coordination while upholding ethical principles such as autonomy, privacy, justice, and beneficence. Slide 4: Legal and Ethical Implications Legally, our elevated readmission rates could expose the hospital to increased malpractice lawsuits due to perceived negligence. For instance, a failure to provide adequate post-discharge instructions could potentially lead to a patient’s condition worsening and subsequent legal actions could ensue. The cost of these lawsuits is not merely financial; they could also significantly harm the hospital’s reputation and trust among the community we serve (Bianco et al., 2023). Moreover, we are subject to the Hospital Readmissions Reduction Program (HRRP) by the Centers for Medicare and Medicaid Services (CMS). Under this program, hospitals with high readmission rates face financial penalties which, given our current situation, could translate into a significant reduction in our annual Medicare reimbursements. Ethically, the high readmission rates call into question our responsibility and commitment to providing the best care for our patients. As a healthcare provider, we have a moral obligation to ensure that our patients receive comprehensive, effective treatment and supportive post-discharge care. Our current readmission rates suggest a potential failing in this duty. This not only impacts our patients’ health outcomes but also affects their trust in our healthcare services (Wright et al., 2023). Thus, it’s essential to view these readmission rates as a reflection of our care quality, and make improvements to fulfill our ethical obligation to our patients. Slide 5: Best Practices and Comparison to Current Practices Upon a thorough review of available literature and benchmarking against best-performing hospitals, several interventions emerge as promising strategies to curb high readmission rates. The two most compelling strategies involve improved care coordination and enhanced patient education. Our current care coordination practices are primarily confined to the hospital setting. A discharge plan is formulated by the healthcare team, and the patient or their caregiver receives these instructions at the time of discharge. The current outcomes of the plan indicate that it’s not effective in maintaining long-term patient adherence, there is insufficient post-discharge support and follow-up, and overall patient satisfaction scores remain moderate.  However, it seems that the impact of