- NURS FPX 6614 Assessment 1 Defining a Gap in Practice: Executive Summary.
Defining a Gap in Practice: Executive Summary
This summary will analyze clinical priorities for the Medicare-approved hip and knee replacement population to influence health outcomes utilizing care coordination processes. A PICOT question will address a gap in care coordination practice. Care coordination services and resources available for this population will be evaluated using evidence-based practice care coordination interventions to best care for this population.
A selected nursing diagnosis will maintain a collaborative care strategy with a conversation of intervention planning and expected outcomes for the care coordination process using the expansion and standards of practice for care coordination.
Clinical Priorities for Lower Joint Replacement Population to Influence Outcomes
Many hospitals require their Medicare-approved lower joint replacement medical strategy patients to attend pre-surgical education with the care coordination team. This pre-surgical education’s primary goal is to assess and address any social determinants of health(SDOH) patients may be experiencing before a medical system in order to improve healthcare quality, avoid discharge delays, control costs after hospital discharge, and prevent readmissions(Centers for Medicare and Medicaid Services, n.d.).
Hospitals are penalized for under 30-day readmissions and skilled nursing facility (SNF) spending, and how hospitals decide to diminish these expenses is their choice (Zhu et al., 2018). As explored in NURS FPX 6614 Assessment 1 Defining a Gap in Practice – Executive Summary, hospitals are moving more toward locally established care and are hiring dedicated care coordination staff like local area health workers (CHWs) to continue to follow up on patient care once talented home health services are discontinued, ensuring patients adhere to their home care plan (Zhu et al., 2018).
- Role of CHWs in Healthcare
The guidance of CHWs assists patients in keeping follow-up appointments and helps with any expected resources, including monitoring and reporting health outcomes to the primary physician or specialist. CHWs are a part of a collaborative team, such as sustaining cases. Managers, social workers(SW), and dieticians who work behind the scenes from medical practices to assist patients with high-risk or complex care needs to decrease high crisis department (ED) utilization and readmissions.
Zhu et al., 2018 report that there is a ton of literature reporting on the advantages of locally situated care utilizing CHWs, yet there is a gap in knowing whether home discharges post-medical strategy without assistance from CHWs could increase hospital readmissions or harm patients with more complicated needs(p.1286).
PICOT Question
In adult patients with total lower joint replacement medical strategy (Population), how valuable is the utilization of CHWs in locally situated care after a medical framework (Intervention) compared to home discharges without the utilization of CHWs(Comparison) in improving quality of care and recuperation (Result) during the postoperative and recuperation time (Time)?
Selected Gap Explanation
Once discharged from the hospital to home and when the talented services are finished, the real battle is getting the patient to participate in their care for the drawn-out length and maintain compliance with the healthcare plan and follow-up appointments(Kangovi et al., 2020). The assumption can not be made that all CHWs’ efforts will forestall unnecessary (ED) visits.
There will always be behaviors that can not be changed, patients who will not participate in care coordination and remain defiant, and individuals who continually make unfortunate healthcare choices(Zhu et al.,2018). Zhu et al., 2018 also report that they did not interview care coordinators or CHWs whose viewpoints may contrast with those of healthcare suppliers and specialists regarding their points of view concerning the impact of utilizing CHWs or not in the homes for postsurgical patients(p.1284).
Available Care Coordination Services and Resources
Care coordination with the patient and family starts before a medical strategy. The specialist’s office collaborates with hospital case managers, surgical unit medical attendants, home health liaisons, physical therapists, and pharmacists to provide planned joint replacement patients with extensive joint education. The workplace medical strategy scheduler arranges the vast week’s education classes for the patients. Patients attend the class in the hospital, so they know exactly where to come on the day of the medical strategy.
NURS FPX 6614 Assessment 1 Defining a Gap in Practice: Executive Summary
A plunk-down conversation is held, and each hospital discipline talks with the patients and any family who attend to examine a medical plan, home-going expectations, medications, social determinants of health(SDOH), caregiver work, and durable medical equipment(DME). A question-and-answer meeting for the patients and families is introduced at the end of the class. The goal is to meet face-to-face with patients and families, assess needs, and prepare patients for home-going to avoid unnecessary discharge delays and skilled nursing facility(SNF) referrals(Mendel et al., 2018).
This pre-medical procedure education also assists patients with planning pre-medical strategy interventions and educates them on expected outcomes after the medical framework. Patients and families are educated regarding transitions to a CHW once gifted services are finished. In this collaborative relationship with patients and families, a feeling of trust is created with their supplier, and patients meet a team who will be caring for them in the hospital, which strengthens patients and families(Zhu et al.,2018).
Evidence-based Care Coordination Intervention
The care coordination guidance given to the Medicare-approved hip and knee replacement population is based on The Selected Attendant Care Coordination Transition Management Model (RN CCTM). The American Academy of Ambulatory Care Nursing (2016) states that this model has brilliant light on individualized patient-focused assessment and care planning and advanced to standardize all selected medical attendants’ work using evidence from nursing and interprofessional literature on care coordination and transition management(p.8).
- Care Coordination and Transition Management
The RN CCTM model is an awe-inspiring light on care coordination and collaboration with the multidisciplinary team. It offers an individual-focused approach to patient care to engage and encourage patients to collaborate with their healthcare providers. A critical part of care coordination is preparing for the transition management of care, and this is where the utilization of CHWs plays a key role. Transition management assists patients and families as they navigate their longitudinal healthcare journey(The American Academy of Ambulatory Care Nursing, 2016).
Care coordination is about assessing individual care needs, tailoring care to that patient, identifying patient dangers, and, based on those dangers or necessities, providing the most appropriate care services for the transition management care.
Nursing Diagnosis
Readiness for Enhanced Individual Coping is evidenced by verbalizing the desire for information from a local health coach that will enhance optimal health outcomes and further encourage healing(Phelps et al., 2017).
Issue Assessment
The patient will display a readiness for enhanced individual coping by collaborating with the care coordination team and expressing a willingness to accept further assistance from the CHW to achieve optimal health outcomes. The patient will also work on healing by maintaining follow-up appointments and accepting local area resources and guidance from the CHW.
Planning Interventions and Expected Outcomes
A multidisciplinary collaboration must begin at the start of care, not significantly before the transition, including the patient and family(American Academy of Ambulatory Care Nursing, 2016). Then, care coordination necessitates seeing patients in danger of unnecessary readmission or ED utilization by assessing health literacy, SDOH, trust in taking care of oneself, the intricacy of any comorbidities, and their discharge condition(American Academy of Ambulatory Care Nursing, 2016).
Lastly, transitional planning is more than the patient’s discharge instructions; it involves coordination with all of the appropriate care suppliers necessary to guarantee that the patient is transitioned home with understandable discharge instructions and home health services and determining the essentials for a CHW once talented services are complete(American Academy of Ambulatory Care Nursing, 2016).
To achieve outcomes for patients and families, the goals should be achievable based on their inclinations and values, and it is essential to include them in choice-making (American Academy of Ambulatory Care Nursing, 2016). Expected outcomes will be evidenced by patients and families verbalizing understanding of alluded local area resources and maintaining follow-up appointments arranged by CHW(American Academy of Ambulatory Care Nursing, 2016).
The family and patient will accurately portray the disease cycle, feelings about self-management of their healthcare, and healthcare follow-up (American Academy of Ambulatory Care Nursing, 2016). Outcomes will coordinate care across the healthcare continuum using an exhaustive, individual-focused, evidence-based approach to attaining patient goals (American Academy of Ambulatory Care Nursing, 2016). This aligns with the objectives of NURS FPX 6614 Assessment 1 Defining a Gap in Practice – Executive Summary, which focuses on identifying and addressing gaps in healthcare practices to improve patient outcomes.
References
American Academy of Ambulatory Care Nursing (2016). Scope and Standards of Practice for Registered Nurses in Care Coordination and Transition Management. 1-40. https://ebookcentral-proquest-com.library.capella.edu/lib/capella/detail.action?docID=4768806#
Centers for Medicare & Medicaid Services. (n.d.). BPCI Model 2: Retrospective acute & post-acute care episode | CMS innovation centre. CMS Innovation Center CMS Innovation Center. https://innovation.cms.gov/innovation-models/bpci-model-2
Kangovi, S., Mitra, N., Grande, D., Long, J. A., & Asch, D. A. (2020). An evidence-based community health worker program addresses unmet social needs and generates positive returns on investment. Health Affairs, 39(2), 207-213,213A-213C. doi:http://dx.doi.org.library.capella.edu/10.1377/hlthaff.2019.00981
Mendel, P., Chen, E. K., Green, H. D., Armstrong, C., Timbie, J. W., Kress, A. M., Friedberg, M. W., & Kahn, K. L. (2018). Pathways to Medical Home Recognition: A Qualitative Comparative Analysis of the PCMH Transformation Process. Health services research, 53(4), 2523–2546. https://doi.org/10.1111/1475-6773.12803
Naylor, J. M., Hart, A., Harris, I. A., & Lewin, A. M. (2019). Variation in rehabilitation after uncomplicated total knee or hip arthroplasty: A call for evidence-based guidelines. BMC Musculoskeletal Disorders, 20 doi:http://dx.doi.org.library.capella.edu/10.1186/s12891-019-2570-8
Phelps, L. L., Ralph, S. S., & Taylor, C. M. (2017). Sparks and Taylor’s Nursing Diagnosis Reference Manual (Tenth rev. ed.). Wolters Kluwer Health.
Zhu, J. M., Patel, V., Shea, J. A., Neuman, M. D., & Werner, R. M. (2018). Hospitals Using Bundled Payment Report Reducing Skilled Nursing Facility Use And Improving Care Integration. Health Affairs, 37(8), 1282-1289,1289A-1289B. http://dx.doi.org.library.capella.edu/10.1377/hlthaff.2018.0257