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NURS FPX 6614 Assessment 1 Defining a Gap in Practice

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    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


    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.


    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., & Snobelen, N. (2023). Implementation and impacts of virtual team-based care planning for older persons in formal care settings: A scoping review. DIGITAL HEALTH, 9, 205520762311515. 

    NURS FPX 6614 Assessment 1 Defining a Gap in Practice

    Hovsepian, V. E., McHugh, M. D., & Kutney-Lee, A. (2023). Electronic health record usability and post-surgical outcomes among older adults with dementia. The American Journal of Geriatric Psychiatry. 

    Innab, A. M. (2022). Nurses’ perceptions of fall risk factors and fall prevention strategies in acute care settings in Saudi Arabia. Nursing Open, 9(2). 

    Liu, Q., Yu, Y., Wu, X., Sun, Y., Lyu, Y., Cao, K., Wang, Y., & Geng, L. (2023). Demand for community medical-nursing combined services among the empty-nest elderly in China: A qualitative study. Health & Social Care in the Community, 2023, e2173057. 

    Strachna, O., Asan, O., & Stetson, P. D. (2022). Managing critical patient-reported outcome measures in oncology settings: System development and retrospective study. JMIR Medical Informatics, 10(11), e38483. 

    NURS FPX 6614 Assessment 1 Defining a Gap in Practice

    Vareta, D. A., Ventura, F., Família, C., & Oliveira, C. (2022). Person-centered practice in hospitalized older adults with chronic illness: Clinical study protocol. International Journal of Environmental Research and Public Health, 19(17), 11145. 

    Wolff, J. C., Maron, M., Chou, T., Hood, E., Sodano, S., Cheek, S., Thompson, E., Donise, K., Katz, E., & Mannix, M. (2023). Experiences of child and adolescent psychiatric patients boarding in the emergency department from staff perspectives: Patient journey mapping. Administration and Policy in Mental Health and Mental Health Services Research, 50, 417–426.