NURS FPX 6610 Assessment 1
Comprehensive Needs Assessment
Name
Capella University
FPX 6610: Introduction to Care Coordination
Instructor’s Name
February 2024
Comprehensive Needs Assessment
Within this assessment, the intricate landscape of care coordination within the healthcare system is explored, with a focus on the pivotal role of nurses in facilitating continuity of care and patient safety. As the healthcare environment evolves, challenges and opportunities surrounding care coordination evolve accordingly. Insights from the Vila Health simulation and current evidence-based practices are drawn upon to identify gaps in patient care. Through analysis from a patient-centered perspective, a comprehensive understanding of the complexities inherent in care coordination and its profound implications for enhancing healthcare delivery and patient well-being is sought.
Current Gaps in the Patient’s Care
Mr. Decker is a diabetic patient whose healthcare journey highlights the intricacies and challenges of care coordination within the healthcare system. Following a hospitalization, Mr. Decker’s needs extend beyond medical treatment, encompassing aspects such as post-discharge planning, rehabilitation, and social support. Based on a comprehensive needs assessment that incorporates patient-reported data, several gaps in Mr. Decker’s care become apparent. Firstly, there appears to be a lack of adequate post-hospitalization support and coordination. Despite efforts to arrange for assistance from family members, the reliability and sufficiency of this support system remain uncertain, leaving Mr. Decker vulnerable to gaps in care management upon discharge. Furthermore, the financial constraints hindering access to a rehabilitation facility exacerbate the challenge of ensuring continuity of care for Mr. Decker’s recovery. This highlights a critical gap in addressing the socioeconomic factors impacting his ability to access essential healthcare services.
Moreover, transportation barriers emerge as another significant gap in Mr. Decker’s care. The limited mobility and lack of reliable transportation options pose a considerable challenge in accessing necessary medical appointments and follow-up care, potentially compromising the effectiveness of treatment and recovery efforts. Without adequate transportation solutions in place, there is a risk of missed appointments, delayed treatments, and overall suboptimal management of Mr. Decker’s health condition. Addressing these gaps in care coordination, particularly regarding post-discharge support and transportation accessibility, is imperative to ensure Mr. Decker receives comprehensive, patient-centered care aligned with his healthcare needs and preferences.
Strategy for Gathering Additional Necessary Data
Firstly, interdisciplinary collaboration among healthcare professionals involved in Mr. Decker’s care is essential. This includes nurses, physicians, social workers, and case managers, who collectively contribute to a comprehensive understanding of his medical, social, and financial circumstances. Regular multidisciplinary team meetings allow for information sharing and collaborative decision-making (Couturier et al., 2022).
Secondly, patient-reported outcomes measures (PROMs) and patient-reported experience measures (PREMs) must be included into the assessment process. Given Mr. Decker’s unique situation and preferences, utilizing standardized tools to capture his subjective experiences and concerns is paramount. By routinely collecting PROMs and PREMs, healthcare providers can gain insights into patient perspectives on health status, treatment outcomes, and care experiences (Casaca et al., 2023). This feedback not only informs care planning but also fosters a patient-centered approach that aligns with individual needs and goals.
Additionally, conducting comprehensive functional assessments and environmental evaluations is vital in Mr. Decker’s case. Assessing physical abilities, functional status, and activities of daily living helps identify any impairments or limitations that may affect the ability to manage patients’ health independently (Patrizio et al., 2020). Furthermore, evaluating Mr. Decker’s home environment, social support network, and access to resources such as transportation is essential. Home visits or collaboration with community-based organizations can provide valuable insights into Mr. Decker’s living situation and social determinants of health, guiding tailored interventions and support services. By implementing these strategies, healthcare providers can gather comprehensive assessment data that informs a patient-centered care plan specifically designed to meet Mr. Decker’s unique needs and circumstances.
Societal, Economic, and Interdisciplinary Factors Affecting Patient Care
A number of factors with definite cause-and-effect correlations backed by reliable evidence are probably going to have an impact on patient outcomes. First of all, socioeconomic variables are important, including access to healthcare services and budgetary limitations. Studies reveal that people with a lower socioeconomic class frequently encounter obstacles while attempting to obtain timely and adequate healthcare, which can result in differences in health outcomes (McMaughan et al., 2020). For Mr. Decker, the inability to afford a rehabilitation facility may result in suboptimal recovery and prolonged recovery times, ultimately impacting his overall health outcomes. Studies have shown that socioeconomic disparities contribute to variations in healthcare utilization, treatment adherence, and health outcomes, highlighting the importance of addressing these factors in care planning to improve patient outcomes (Garney et al., 2021).
Secondly, social support networks and the availability of caregiver support can profoundly influence patient outcomes (Kim et al., 2022). In Mr. Decker’s case, the reliability and sufficiency of support from his family members, particularly his daughter and nephew, may significantly impact his ability to manage his health condition post-discharge. Studies have demonstrated that patients with adequate social support experience better emotional well-being, reduced stress levels, and enhanced self-care abilities, leading to improved treatment outcomes and quality of life (Leung et al., 2020).
Furthermore, the accessibility and coordination of healthcare services also play a crucial role in determining patient outcomes. Studies have shown that fragmented healthcare delivery systems and poor care coordination contribute to adverse outcomes, including medication errors, treatment delays, and hospital readmissions (Roberts et al., 2022). For Mr. Decker, transportation barriers and gaps in care coordination may hinder his access to follow-up appointments, medication management, and rehabilitation services, increasing the risk of complications and compromising his recovery.
Standards Influence on Patient Care and Care Coordination Outcomes
Professional standards set by organizations such as the American Nurses Association (ANA) emphasize the importance of care coordination in promoting patient safety, continuity of care, and positive health outcomes. By adhering to ANA standards, healthcare providers can prioritize activities such as comprehensive patient assessments, interdisciplinary collaboration, and communication to ensure effective care coordination (Creta & Gross, 2020).
Moreover, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores can be directly related to professional standards regarding patient-centered care and communication. The HCAHPS survey assesses patients’ perceptions of their hospital experience, including aspects such as nurse communication, care coordination, and discharge planning (Hurwitz et al., 2023). By meeting or exceeding HCAHPS benchmarks, healthcare organizations demonstrate adherence to professional standards that prioritize patient engagement, shared decision-making, and effective communication (Hurwitz et al., 2023). Consequently, healthcare providers can justify their practices by articulating clear relationships between patient outcomes, such as improved HCAHPS scores.
Evidence-Based Practices for Successful Implementation of Patient Care Coordination
One evidence-based practice involves leveraging data analytics and health informatics to identify population health trends and risk factors. By analyzing data from electronic health records, health surveys, and community assessments, healthcare providers can identify high-risk populations, prevalent health issues, and disparities in healthcare access (Rehman et al., 2021). This data-driven approach enables proactive interventions and targeted outreach efforts to promote preventive care, disease management, and health promotion initiatives tailored to the specific needs of the population. Studies have shown that leveraging data analytics improves health outcomes, reduces healthcare costs, and enhances population health management strategies, making it a necessary practice for successful care implementation from a population-health perspective (Rehman et al., 2021).
Furthermore, fostering community partnerships and collaborations is essential for implementing a population-health plan effectively. Engaging community stakeholders facilitates a coordinated approach to address social determinants of health and promote community wellness (Cronin et al., 2021). By partnering with community organizations, healthcare providers can leverage existing resources, infrastructure, and expertise to deliver comprehensive health services, outreach programs, and health education initiatives that resonate with the population’s cultural and social context. Evidence suggests that community partnerships improve health equity, increase access to care, and empower individuals and communities to adopt healthier behaviors, making it a critical practice for successful population-health interventions (Cronin et al., 2021).
Benefits of Multidisciplinary Approach to Patient Care
Multidisciplinary approach, facilitated by a robust care coordination plan, offers numerous benefits that enhance patient outcomes and overall healthcare delivery. Firstly, such an approach allows for comprehensive assessment and management of patients’ complex needs by drawing on the expertise of various healthcare professionals. For example, a team comprising physicians, nurses, social workers, pharmacists, and therapists can collectively address medical, psychosocial, and rehabilitative aspects of patient care. Research consistently demonstrates that interdisciplinary collaboration leads to improved clinical outcomes, reduced hospital readmissions, and enhanced patient satisfaction (Taberna, 2020). Multidisciplinary teams in primary care settings resulted in better management of chronic conditions and higher patient adherence to treatment plans, underscoring the effectiveness of collaborative care models.
Moreover, a multidisciplinary approach promotes continuity and coherence in patient care by facilitating seamless transitions across healthcare settings and specialties. By fostering open communication and information sharing among team members, care coordination plans ensure that patients receive integrated and consistent care throughout their healthcare journey (Taberna, 2020). Evidence suggests that coordinated care models reduce medical errors, unnecessary duplication of services, and gaps in care, leading to improved care quality and patient safety (Taberna, 2020). For instance, a systematic review published in the Annals of Internal Medicine found that care coordination interventions, particularly those involving multidisciplinary teams, were associated with reduced hospitalizations and emergency department visits.
Conclusion
This assessment underscores the critical importance of care coordination in optimizing patient outcomes and fostering healthcare excellence. By identifying gaps in patient care, exploring the multifaceted factors influencing outcomes, and advocating for a multidisciplinary approach, key strategies to enhance care coordination practices are illuminated. Moving forward, healthcare professionals must continue leveraging evidence-based practices, interdisciplinary collaboration, and patient-centered care models to address evolving challenges in care coordination and uphold the highest standards of quality, safety, and patient satisfaction in healthcare delivery.
References
Casaca, P., Schäfer, W., Nunes, A. B., & Sousa, P. (2023). Using patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) to elevate the quality of healthcare. International Journal for Quality in Health Care, 35(4). https://doi.org/10.1093/intqhc/mzad098
Couturier, Y., Lanoue, S., Karam, M., Guillette, M., & Hudon, C. (2022). Social workers coordination in primary healthcare for patients with complex needs: A scoping review. International Journal of Care Coordination, 26(1), 205343452211229. https://doi.org/10.1177/20534345221122952
Creta, A. M., & Gross, A. H. (2020). Components of an effective professional development strategy: The professional practice model, peer feedback, mentorship, sponsorship, and succession planning. Seminars in Oncology Nursing, 36(3), 151024. https://doi.org/10.1016/j.soncn.2020.151024
Cronin, C. E., Franz, B., & Garlington, S. (2021). Population health partnerships and social capital: Facilitating hospital-community partnerships. SSM – Population Health, 13, 100739. https://doi.org/10.1016/j.ssmph.2021.100739
Garney, W., Wilson, K., Ajayi, K. V., Panjwani, S., Love, S. M., Flores, S., Garcia, K., & Esquivel, C. (2021). Social-ecological barriers to access to healthcare for adolescents: A scoping review. International Journal of Environmental Research and Public Health, 18(8), 4138. https://doi.org/10.3390/ijerph18084138
Hurwitz, H. M., Mercer, M., & Rose, S. L. (2023). Interventions that improve patient experience evidenced by raising HCAHPS and CG-CAHPS Scores: A narrative literature review. Patient Experience Journal, 10(1), 107–114. https://doi.org/10.35680/2372-0247.1669
Kim, K. T., Hawkins, B. A., Lee, Y.-H., & Kim, H. (2022). Social support and daily life activity: Determinants of aging well. Activities, Adaptation & Aging, 1–24. https://doi.org/10.1080/01924788.2022.2106013
Leung, D. Y. P., Chan, H. Y. L., Chiu, P. K. C., Lo, R. S. K., & Lee, L. L. Y. (2020). Source of social support and caregiving self-efficacy on caregiver burden and patient’s quality of life: A path analysis on patients with palliative care needs and their caregivers. International Journal of Environmental Research and Public Health, 17(15), 5457. https://doi.org/10.3390/ijerph17155457
McMaughan, D. J., Oloruntoba, O., & Smith, M. L. (2020). Socioeconomic status and access to healthcare: Interrelated drivers for healthy aging. Frontiers in Public Health, 8(231). https://doi.org/10.3389/fpubh.2020.00231
Patrizio, E., Calvani, R., Marzetti, E., & Cesari, M. (2020). Physical functional assessment in older adults. The Journal of Frailty & Aging, 1–9. https://doi.org/10.14283/jfa.2020.61
Rehman, A., Naz, S., & Razzak, I. (2021). Leveraging big data analytics in healthcare enhancement: Trends, challenges and opportunities. Multimedia Systems, 28(4). https://doi.org/10.1007/s00530-020-00736-8
Roberts, T. J., Bailey, A. S., Tahir, N., & Jacobson, J. O. (2022). Care fragmentation, faulty communication, and documentation lapses derail a treatment plan. JCO Oncology Practice. https://doi.org/10.1200/op.22.00471
Taberna, M. (2020). The multidisciplinary team (MDT) approach and quality of care. Frontiers in Oncology, 10(85). https://doi.org/10.3389/fonc.2020.00085
Susie Taylor is an expert in Capella FlexPath Nursing programs, with years of experience helping nursing students succeed. She combines practical nursing knowledge with a deep understanding of Capella’s flexible, self-paced learning.
