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NURS FPX 6616 Assessment 1 Community Resources and Best Practices

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    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


    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 these instructions dwindles over time, considering our high readmission rates. Comparatively, hospitals with lower readmission rates follow a more proactive care coordination model. They employ a dedicated team that not only formulates an individualized discharge plan but also ensures follow-up via telephonic or in-person visits. These follow-ups allow healthcare professionals to address any complications or misunderstandings in a timely manner, thus reducing the chances of readmission (Bianco et al., 2023). 

    NURS FPX 6616 Assessment 1 Community Resources and Best Practices

    Regarding patient education, we currently provide patients with written educational materials at discharge. However, this one-size-fits-all approach may be insufficient.  The current outcomes of this practice show that many patients struggle to fully understand these materials, they fail to properly follow medical instructions post-discharge, and our patient survey results indicate that the current education practice does not sufficiently meet their needs. Studies have shown that personalized education, which involves tailoring information to each patient’s unique needs, comprehension level, and lifestyle, can enhance understanding and adherence to care instructions, subsequently reducing readmission rates (Wright et al., 2023).

    Implementing these best practices can support ethical and legal practices. From a legal perspective, proactive care coordination and personalized education could minimize negligence claims, as they provide ample opportunities to address any misunderstandings or complications. From an ethical standpoint, these practices prioritize patient welfare, demonstrating our commitment to providing high-quality, patient-centered care, and thereby reducing the chances of readmission (Fountoulaki et al., 2022).

    Slide 6: Evidence-based Intervention and Role of Stakeholders Involved

    The evidence-based intervention that shows promise in reducing readmissions is the “Transitional Care Model” (TCM). Developed by Dr. Mary Naylor and her colleagues at the University of Pennsylvania, TCM has demonstrated substantial success in reducing readmission rates among chronically ill older adults (Suksatan & Tankumpuan, 2021). TCM is designed to provide high-risk older adults with comprehensive in-hospital planning and home follow-up. This model has been shown to reduce readmission rates by 20-50%, depending on the patient population and the specifics of the implementation. Additionally, TCM also improves health outcomes and reduces healthcare costs, making it beneficial for both patients and healthcare providers.

    The stakeholders affected by the implementation of this intervention are wide-ranging and include both individuals and organizations. First and foremost, our patients stand to benefit from the personalized care and comprehensive follow-up, leading to improved health outcomes and potentially higher satisfaction rates. In the context of chronic disease patients, who constitute a large proportion of our readmission rates, the impact could be substantial.

    Our healthcare organization and professionals, including doctors, nurses, and care coordinators, are pivotal stakeholders. The implementation of TCM will necessitate training and potential restructuring of responsibilities, leading to a more collaborative, team-based approach to patient care. Finally, external stakeholders such as insurance companies and policy-making bodies like the CMS could also be affected. Reduction in readmission rates could lead to lower healthcare costs, influencing reimbursement policies and premiums (Bianco et al., 2023). Moreover, the patients’ caregivers or families, who often play a crucial role in managing post-discharge care, can also be considered vital stakeholders. TCM’s emphasis on home follow-up and caregiver involvement can empower them with the knowledge and resources needed to provide effective care at home.

    Slide 7: Role of Interprofessional Team for the Intervention

    The successful implementation of the Transitional Care Model (TCM) requires robust interprofessional support, as it is built upon the synergy of various healthcare professionals’ expertise. Physicians play a pivotal role as they are primarily responsible for the patient’s medical care. They will need to actively communicate and collaborate with other team members to ensure that the patient’s medical needs are accurately incorporated into the personalized care plan. Moreover, physicians will need to closely monitor the patient’s health status and adjust the care plan as necessary, based on inputs from the rest of the team (Renouf et al., 2022).

    Nurses, particularly those specialized in transitional care, will be at the forefront of this intervention. They are the ones who establish a comprehensive discharge plan and follow up with patient’s post-discharge. They act as a bridge between the patient and the healthcare system, ensuring the patient’s needs are addressed, and any complications are identified and managed promptly. Care coordinators have a crucial role in coordinating services across the care continuum. They need to ensure seamless transitions between different care settings (for example, from hospital to home), which involves tasks such as scheduling follow-up appointments, coordinating with home health services, and ensuring medication reconciliation.

    NURS FPX 6616 Assessment 1 Community Resources and Best Practices

    Social workers provide another layer of support by assessing the social determinants of health that might affect the patient’s ability to follow the care plan. They can help arrange necessary services, like meal delivery or transportation for follow-up appointments, which can be crucial for adherence to the care plan and prevention of readmissions. The successful application of TCM necessitates this kind of comprehensive, interprofessional collaboration. It emphasizes the significance of each professional’s role, not only in their specific tasks but also in their contribution to the collaborative effort to improve patient outcomes. Supporting this, a study found that care coordination models, like TCM, that incorporate the collaborative efforts of diverse healthcare professionals, significantly reduce readmission rates and enhance the quality of patient care (Wright et al., 2023).

    Slide 8: Approach to Measuring Baseline Data

    Our current data indicates that our hospital’s readmission rate for chronic disease patients, like those with heart disease and diabetes, stands at 25%, which is above the national average of 15%. This discrepancy signifies a significant gap in our practices and underscores the need for a well-defined and comprehensive intervention strategy (Wright et al., 2023). When implementing the Transitional Care Model (TCM), we must have concrete measures in place to evaluate its effectiveness. Several Key Performance Indicators (KPIs) will be pivotal in this process:

    Readmission Rates: We will continue to monitor the 30-day readmission rates as the primary measure of the effectiveness of our intervention. A statistically significant decrease in these rates will indicate that our efforts are yielding positive results.

    Patient Satisfaction Scores: These scores are critical in determining whether our patients feel adequately supported during their transition from the hospital to home care. We will use tools such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to measure this. An increase in our current average score of 70% would suggest improvement in patient perception of their care (O’Donnell et al., 2023).

    NURS FPX 6616 Assessment 1 Community Resources and Best Practices

    Length of Hospital Stay: We will also track the average length of hospital stay for patients with chronic diseases. An effective care coordination strategy should not only reduce readmission rates but also potentially decrease the length of hospital stays. Currently, our average is 5 days, and any reduction in this number would be a positive outcome of our intervention (Suksatan & Tankumpuan, 2021).

    Overall Costs of Care: Lastly, we need to evaluate the financial viability of our intervention. Implementing TCM would require resources, but if effective, it could lead to a significant decrease in overall healthcare costs by reducing readmissions. Therefore, we need to monitor the average cost of care per patient and balance this against the costs of implementing and maintaining the TCM (Suksatan & Tankumpuan, 2021). For a balanced and comprehensive evaluation, we will conduct systematic assessments at specific intervals, say, every quarter for the first year, and then semi-annually thereafter. This approach will allow us to identify trends, measure progress, and adjust our strategy as needed based on these data-driven insights.

    Slide 9: Evaluation Periods and Measurement Strategy

    To monitor and measure the impact of the Transitional Care Model (TCM) on our patient outcomes and overall hospital performance, we will implement a robust and systematic evaluation strategy. The evaluation periods will be scheduled quarterly for the first year after the introduction of the TCM, and semi-annually thereafter. These periodic evaluations are critical for several reasons. First, they allow us to track progress and assess the impact of our intervention on key performance indicators. For instance, if our readmission rates decrease from 25% to 20% in the first quarter after TCM implementation, it will suggest a positive initial impact (O’Donnell et al., 2023).

    Second, frequent evaluations in the early stages of intervention rollout provide us with opportunities to identify and resolve any issues or barriers to effective implementation. For example, if we notice no significant improvement in patient satisfaction scores or a rise in the length of hospital stay, it would prompt us to delve deeper and identify the underlying reasons. Third, these evaluations will enable us to adapt and refine our strategies based on data-driven insights. For instance, if a particular aspect of TCM, say post-discharge follow-up, isn’t working as well as anticipated, the evaluation would allow us to modify our approach (Suksatan & Tankumpuan, 2021).

    The data for these evaluations will be gathered from various sources including patient records, patient surveys, hospital financial data, and inputs from the interprofessional team implementing the intervention. To ensure accurate assessments, we will employ statistical analyses that account for potential confounding variables and provide us with reliable results. By integrating this detailed, systematic, and data-driven evaluation strategy, we will be better equipped to measure the effectiveness of the TCM, make informed adjustments, and thereby enhance the quality of care coordination, reducing readmission rates, and ultimately improving patient outcomes.

    Slide 10: Recommendations for Sustaining Intervention Outcomes

    Maintaining the gains achieved through the Transitional Care Model (TCM) will require a long-term commitment to ongoing staff development, interprofessional communication, procedural reassessments, and patient feedback. Here is a more detailed approach to each:

    Continuous Staff Development: To ensure the continuous delivery of effective patient care, we recommend a sustained commitment to staff training and professional development. Staff should be updated about the latest evidence-based practices in care coordination and patient education through regular workshops, seminars, and online training modules. For example, bi-monthly seminars and weekly interactive learning sessions can be conducted to reinforce key aspects of TCM and resolve any issues faced by the team (Wright et al., 2023).

    Consistent Interprofessional Communication: The TCM thrives on effective interprofessional collaboration and communication. Hence, we suggest the establishment of routine meetings for the entire care team, perhaps bi-weekly or monthly, where everyone can discuss patient cases, share experiences, and develop collective strategies. Such meetings can help in identifying gaps in care delivery and suggest ways to improve.

    NURS FPX 6616 Assessment 1 Community Resources and Best Practices

    Routine Reassessment of Procedures: Just as medicine is constantly evolving, so too should our care procedures. We propose conducting an annual audit of our care coordination procedures to ensure they continue to align with best practices and are responsive to any changes in legislation or healthcare standards. This audit should be comprehensive, covering all aspects of patient care, from initial hospital admission to post-discharge follow-up (Bianco et al., 2023).

    Continuous Patient Feedback: Our patients are the ultimate beneficiaries of our care coordination efforts, so their feedback is crucial. We should actively seek patient input through regular surveys, post-discharge follow-up calls, and open lines of communication for them to share their experiences. A feedback mechanism, such as a quarterly patient satisfaction survey, should be implemented to gain insights directly from the patients and their families (Zumbrunn et al., 2022).

    Slide 11: Conclusion

    In conclusion, we have addressed the pressing challenge of reducing our hospital’s readmission rates, a matter of significant ethical and legal implications. We delved into the efficacy of the Transitional Care Model, an evidence-based intervention promising substantial improvements in our care coordination. Interprofessional collaboration, a core component of this model, was discussed in detail, highlighting the roles of healthcare professionals such as physicians, nurses, care coordinators, and social workers.

    We have outlined a comprehensive strategy for collecting baseline data, establishing key performance indicators, and regularly evaluating our progress through robust measurement strategies. Recommendations for maintaining the longevity of the intervention’s outcomes were also presented, emphasizing the importance of continuous staff development, consistent interprofessional communication, procedural reassessments, and patient feedback. As we seek to implement these changes, your support will be pivotal in enhancing the quality of care we offer to our patients and effectively decreasing readmission rates.

    Slide 12: References

    Bianco, G. L., Tinnirello, A., Papa, A., Marchesini, M., Day, M., Palumbo, G. J., Terranova, G., Dato, M. T. D., Thomson, S. J., & Schatman, M. E. (2023). Interventional pain procedures: A narrative review focusing on safety and complications. Part 2 interventional procedures for back pain. Journal of Pain Research, 16, 761–772. 

    Fountoulaki, K., Ventoulis, I., Drokou, A., Georgarakou, K., Parissis, J., & Polyzogopoulou, E. (2022). Emergency department risk assessment and disposition of acute heart failure patients: Existing evidence and ongoing challenges. Heart Failure Reviews. 

    O’Donnell, L., George, E., Donnelly, J., Bilderback, A., & Buchanan, D. (2023). Coaching to bedside shift report and its correlation to hospital consumer assessment of healthcare providers and systems and value-based purchasing dimension scores. JONA: The Journal of Nursing Administration, 53(1), 12–18.

    NURS FPX 6616 Assessment 1 Community Resources and Best Practices 

    Renouf, T., Bates, A., Davis, J. F., & Jack, S. (2022). Prehabilitation. An interdisciplinary patient-centric conceptual framework. Seminars in Oncology Nursing, 151329. 

    Suksatan, W., & Tankumpuan, T. (2021). The effectiveness of transition care interventions from hospital to home on rehospitalization in older patients with heart failure: An integrative review. Home Health Care Management & Practice, 108482232110238. 

    Wright, B., Parrish, C., Basu, A., Joynt, K. E., Liao, J. M., & Sabbatini, A. K. (2023). Medicare’s hospital readmissions reduction program and the rise in observation stays. Health Services Research. 

    Zumbrunn, A., Bachmann, N., Bayer-Oglesby, L., & Joerg, R. (2022). Social disparities in unplanned 30-day readmission rates after hospital discharge in patients with chronic health conditions: A retrospective cohort study using patient level hospital administrative data linked to the population census in Switzerland. PLOS ONE, 17(9), e0273342.