Name
Capella University
FPX6610: Introduction to Care Coordination
Instructor’s Name
February 2024
NURS FPX6610 Assessment 4 Care Presentation
Care Presentation
Hello, I extend a warm welcome to today’s presentation focusing on the case of Mrs. Rebecca Snyder.
The primary objective is to provide a comprehensive overview of Mrs. Snyder’s medical history, current health status, and the proposed plan for continuing care. Mrs. Snyder’s journey is marked by the complexities of ovarian cancer, uncontrolled diabetes, and hyperglycemia, underscoring the critical importance of effective care coordination and interdisciplinary collaboration. Through this presentation, I aim to foster a shared understanding of Mrs. Snyder’s unique needs and empower stakeholders to contribute to her care plan with clarity, compassion, and purpose.
Goals, Elements and Scope of Continuing Care
The overarching goal of Mrs. Snyder’s continuing care plan is to optimize her quality of life and ensure that her healthcare needs are met with compassion, dignity, and respect throughout her journey with terminal ovarian cancer, uncontrolled diabetes, and hyperglycemia. The plan encompasses a multidimensional approach that addresses her medical, physical, psychological, social, and spiritual needs. At its core, the plan aims to provide seamless transitions between healthcare settings while maintaining continuity of care and supporting Mrs. Snyder’s preferences and values.
Key elements of the continuing care plan include comprehensive symptom management to alleviate pain and discomfort associated with her conditions, ongoing monitoring and assessment of her physical and psychological well-being, and coordination of healthcare services across different providers and settings. Additionally, the plan incorporates advance care planning discussions to clarify Mrs. Snyder’s end-of-life preferences and ensure that her wishes regarding resuscitation, life-sustaining treatments, and goals of care are respected. Cultural sensitivity and respect for her religious beliefs are also integral components of the plan, with efforts made to identify facilities and services that can accommodate her cultural and religious needs.
Overall Scope
The overall scope of the continuing care plan extends beyond medical interventions to encompass emotional and spiritual support tailored to Mrs. Snyder’s individual needs and preferences. This includes access to counseling services, support groups, and spiritual care, as well as opportunities for emotional expression, coping strategies, and spiritual reflection. Ongoing follow-up and evaluation are essential aspects of the plan to monitor Mrs. Snyder’s condition, address any changes in symptoms or needs, and ensure that her care remains appropriate and responsive to her evolving circumstances. Through the implementation of this comprehensive plan, the aim is to optimize Mrs. Snyder’s overall well-being and enhance her quality of life during this challenging time.
Interprofessional Care Team
Slide 6: An interprofessional care team plays a pivotal role in delivering high-quality patient outcomes by leveraging the expertise of diverse healthcare professionals to provide comprehensive and coordinated care (McCutcheon et al., 2020). In the case of Mrs. Snyder, an interprofessional team comprising physicians, nurses, social workers, palliative care specialists, and other allied healthcare professionals collaborates to address her complex medical, emotional, and social needs. Each team member brings unique skills and perspectives to the table, contributing to a holistic approach that considers all aspects of Mrs. Snyder’s well-being.
Collaboration among team members fosters synergy and enhances the efficiency and effectiveness of care delivery. By working together, healthcare professionals can share knowledge, exchange insights, and pool resources to develop tailored care plans that address Mrs. Snyder’s specific needs and preferences. For example, physicians may focus on managing her cancer-related symptoms and coordinating medical treatments, while nurses provide hands-on care, monitor her vital signs, and assess her response to interventions. Social workers may assist with navigating financial and logistical challenges, while palliative care specialists offer expertise in pain management and end-of-life care (O’Donnell et al., 2023). This multidisciplinary approach ensures that Mrs. Snyder receives comprehensive support across the continuum of care.
Research has consistently shown that interprofessional collaboration leads to improved patient outcomes, including reduced hospital readmissions, enhanced quality of life, and greater satisfaction with care. A study found that patients treated by interprofessional teams experienced better symptom management, higher functional status, and increased adherence to treatment plans compared to those receiving care from individual practitioners (Howell et al., 2020). By harnessing the collective expertise of diverse healthcare professionals, an interprofessional care team can address the complex needs of patients like Mrs. Snyder more effectively, ultimately leading to better outcomes and experiences for patients and their families.
Factors Affecting Patient Outcomes
Slide 9: Several factors can significantly impact outcomes for a patient like Mrs. Snyder, whose case involves a terminal illness and complex medical comorbidities. Firstly, the adequacy of pain and symptom management plays a crucial role in determining Mrs. Snyder’s quality of life and overall well-being. Failure to effectively address her cancer-related symptoms, such as pain, nausea, and fatigue, can lead to considerable distress and functional impairment, diminishing her ability to engage in daily activities and eroding her quality of life (Nekhlyudov et al., 2021). Conversely, proactive and comprehensive symptom management can alleviate suffering, enhance comfort, and promote psychological resilience, thereby improving Mrs. Snyder’s overall prognosis and satisfaction with care.
Another critical factor is the level of support and resources available to Mrs. Snyder and her family throughout her care journey. Social determinants of health, such as access to financial resources, social support networks, and community services, can profoundly influence her ability to cope with her illness and adhere to treatment recommendations. Adequate social support from family members, friends, and healthcare professionals can provide emotional reassurance, practical assistance, and companionship, buffering against the negative impact of stress and isolation on health outcomes (Alcaraz et al., 2020). Moreover, access to palliative care services, including specialized medical and psychosocial support, can further enhance her symptom management and overall quality of life, contributing to more positive treatment outcomes and experiences for both Mrs. Snyder and her loved ones.
Additionally, the effectiveness of communication and coordination among healthcare providers and community agencies can significantly affect Mrs. Snyder’s care outcomes. Clear and timely communication ensures that pertinent information about her diagnosis, treatment plan, and care preferences is accurately conveyed across different care settings, minimizing the risk of errors, delays, or misunderstandings. Conversely, breakdowns in communication or coordination may result in fragmented care, medication errors, or suboptimal treatment decisions, compromising safety and well-being (Weston et al., 2023). Therefore, fostering effective collaboration and information sharing among members of her interprofessional care team, as well as with external stakeholders such as hospice providers and community support services, is essential for optimizing Mrs. Snyder’s care outcomes and ensuring a seamless transition between care settings.
Determination of Required Resources
Implementing continuing care for patients like Mrs. Snyder requires a multifaceted approach that encompasses various resources to ensure comprehensive support and optimal outcomes. Firstly, staffing resources are crucial for delivering high-quality care tailored to Mrs. Snyder’s complex needs. This includes a diverse team of healthcare professionals such as physicians, nurses, social workers, and palliative care specialists who can collaborate to provide holistic and patient-centered care (Melby & Håland, 2021). Adequate staffing levels ensure that Mrs. Snyder receives timely assessments, interventions, and support throughout her care journey, enhancing her overall well-being and satisfaction with care.
Moreover, access to specialized medical equipment and assistive devices is essential for meeting Mrs. Snyder’s physical and functional needs. This may include items such as mobility aids, wound care supplies, and home oxygen therapy equipment, depending on her specific clinical requirements (Ostan et al., 2023). Ensuring the availability of these resources not only promotes Mrs. Snyder’s comfort and safety but also facilitates her ability to remain in her preferred care setting, whether at home or in a hospice facility, thereby supporting her autonomy and dignity.
Additionally, financial resources play a significant role in facilitating access to essential healthcare services and supportive interventions for Mrs. Snyder and her family. This includes coverage for medical treatments, medications, and supportive care services, as well as assistance with transportation costs and other ancillary expenses associated with care (Tieu et al., 2023). Access to financial resources ensures that Mrs. Snyder can afford the care she needs without experiencing undue financial hardship, reducing barriers to accessing necessary services and promoting equitable access to quality care for all patients, regardless of their socioeconomic status.
Conclusion
The case presentation of Mrs. Rebecca Snyder has highlighted the significance of effective care coordination, interdisciplinary collaboration, and patient-centered approaches in ensuring optimal outcomes during transitional care. By addressing the goals, elements, and scope of continuing care, identifying factors influencing patient outcomes, and delineating necessary resources, stakeholders are equipped with the knowledge and insight needed to make informed decisions in Mrs. Snyder’s best interests. Moving forward, it is imperative that we remain committed to leveraging innovative strategies, fostering clear communication, and prioritizing patient empowerment to navigate the complexities of Mrs. Snyder’s care journey and uphold the highest standards of quality and compassion in healthcare delivery.
References
Alcaraz, K. I., Wiedt, T. L., Daniels, E. C., Yabroff, K. R., Guerra, C. E., & Wender, R. C. (2020). Understanding and addressing social determinants to advance cancer health equity in the United States: A blueprint for practice, research, and policy. A Cancer Journal for Clinicians, 70(1), 31–46. https://doi.org/10.3322/caac.21586
Howell, D., Rosberger, Z., Mayer, C., Faria, R., Hamel, M., Snider, A., Lukosius, D. B., Montgomery, N., Mozuraitis, M., & Li, M. (2020). Personalized symptom management: A quality improvement collaborative for implementation of patient reported outcomes (PROs) in “real-world” oncology multisite practices. Journal of Patient-Reported Outcomes, 4(1). https://doi.org/10.1186/s41687-020-00212-x
McCutcheon, L. R. M., Haines, S. T., Valaitis, R., Sturpe, D. A., Russell, G., Saleh, A. A., Clauson, K. A., & Lee, J. K. (2020). Impact of interprofessional primary care practice on patient outcomes: A scoping review. SAGE Open, 10(2), 215824402093589. https://doi.org/10.1177/2158244020935899
Melby, L., & Håland, E. (2021). When time matters: A qualitative study on hospital staff’s strategies for meeting the target times in cancer patient pathways. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06224-7
Nekhlyudov, L., Campbell, G. B., Schmitz, K. H., Brooks, G. A., Kumar, A. J., Ganz, P. A., & Von, D. (2021). Cancer‐related impairments and functional limitations among long‐term cancer survivors: Gaps and opportunities for clinical practice. Cancer, 128(2), 222–229. https://doi.org/10.1002/cncr.33913
O’Donnell, A., Gonyea, J., Wensley, T., & Nizza, M. (2023). High-quality patient-centered palliative care: Interprofessional team members’ perceptions of social workers’ roles and contribution. Journal of Interprofessional Care, 1–9. https://doi.org/10.1080/13561820.2023.2238783
Ostan, R., Varani, S., Giannelli, A., Malavasi, I., Pannuti, F., Pannuti, R., Biasco, G., & Mattioli, A. V. (2023). Distance monitoring of advanced cancer patients with impaired cardiac and respiratory function assisted at home: A study protocol in Italy. Journal of Clinical Medicine, 12(5), 1922. https://doi.org/10.3390/jcm12051922
Tieu, M., Milch, V. E., Crawford, F., Joseph, R., Johal, J., Dick, N., Wallen, M. P., Ratcliffe, J., Agarwal, A., Nekhlyudov, L., Tieu, M., Al-Momani, M., Turnbull, S., Sathiaraj, R., Keefe, D., & Hart, N. H. (2023). Patient navigation across the cancer care continuum: An overview of systematic reviews and emerging literature. CA: A Cancer Journal for Clinicians. https://doi.org/10.3322/caac.21788
Weston, E. J., Jefferies, D., Stulz, V., Glew, P., & McDermid, F. (2023). A global exploration of palliative community care literature: An integrative review. Journal of Clinical Nursing. https://doi.org/10.1111/jocn.16707
