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NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment

Assessment 1: Comprehensive Needs Assessment

Name

Capella University

Introduction to Care Coordination  

Prof. Name

June 24th, 2024

Comprehensive Needs Assessment

Carrying out an in-depth needs assessment is vital for healthcare providers to distribute resources and enhance patient care efficiently (Islam et al., 2023). This analysis uses a simulated patient scenario to evaluate and identify potential healthcare service delivery gaps thoroughly. The primary goal of this assessment is to uncover and address these gaps, thereby enhancing the understanding of patient needs and developing a tailored care plan. By performing a comprehensive needs assessment, healthcare professionals can gain deeper insights into their patients’ healthcare requirements, enabling them to create personalized care strategies. The importance of needs and evaluating assessments in healthcare is emphasized through discussions on successful, research-backed strategies for managing patient care. The goal is to identify current gaps in Mr. Decker’s care by considering various types of patient information. Clinical data should include his age, known allergies, body weight, present medical conditions, and detailed medical history.

Evaluating Key Shortcomings in Mr. Decker’s Care Management

Mr. Decker, a 79-year-old diabetic, received care for a serious toe infection at a Vila Health center. Unfortunately, he was rehospitalized with sepsis caused by challenges in adhering to post-discharge medical instructions to challenges in following medical instructions after his discharge. To improve his care, a detailed and patient-centered needs assessment is essential. Gaining insight into his daily habits, likes, typical behaviors, and interests will allow for care customized to his needs and lifestyle. Moreover, the health needs assessment (HNA) is a systematic tool for identifying Mr. Decker’s unmet health and healthcare needs. It examines the prevalence of health conditions to identify gaps in care, existing healthcare services, and patient outcomes. Patient-reported data may reveal gaps in support for his psychological well-being and social needs. Conveying information in straightforward, understandable terms and strengthening it through subsequent check-up visits or electronic health notifications can greatly decrease the likelihood of problems and rehospitalizations (Kao et al., 2020). This comprehensive approach aims to enhance Mr. Decker’s quality of care, minimize potential complications, and boost his overall satisfaction with the care he receives.

All-Encompassing Method for Collecting Patient Information

To develop a thorough understanding of a patient’s health needs, gathering additional assessment data beyond the initial patient interview is essential, employing a holistic, coordinated care perspective (Islam et al., 2023). Similarly, for Mr. Decker’s health needs, regular multidisciplinary team meetings, including doctors, nurses, dietitians, social workers, and physical therapists, ensure that all aspects of his health are considered. Conducting home visits and environmental assessments provides insights into his living conditions, identifying accessibility issues and potential hazards. Understanding his home environment is crucial for tailoring practical and effective interventions. Telehealth consultations offer continuous support and data collection regarding Mr. Decker’s progress, enabling regular check-ins and prompt management of emerging issues. This continuous engagement helps maintain care momentum and prevents future complications. By implementing these strategies, healthcare providers can gather comprehensive data that addresses Mr. Decker’s health needs, ensuring a holistic, patient-centered approach to his care.

Impact of Socioeconomic Factors on Patient Outcomes

Multiple social, economic, and interprofessional elements greatly impact the results of Mr. Decker’s treatment. Societal issues such as ageism and social isolation are particularly relevant. Elderly patients, such as Mr. Decker, frequently encounter biases about their capacity to follow medical advice, leading to lower compliance and poorer health outcomes. Social isolation can exacerbate these issues by reducing access to support networks, further impacting his ability to manage his health effectively. Economic constraints also play a critical role. Limited financial resources may prevent Mr. Decker from affording necessary medications, following recommended dietary changes, or accessing reliable transportation to healthcare facilities. Economic instability can lead to non-compliance with treatment plans and increased health complications (Luconi et al., 2022).

Interprofessional collaboration is another crucial factor. Effective communication and coordination among healthcare providers, like doctors, nurses, and social workers, are vital for providing a unified and thorough care plan (Pasquel et al., 2021). The absence of coordination may lead to fragmented care, medical errors, and suboptimal results. A study by Buléon et al. (2022) has shown that strong interprofessional teamwork improves patient satisfaction, reduces errors, and enhances health outcomes. By addressing these societal, economic, and interprofessional factors, healthcare providers can improve Mr. Decker’s health outcomes and enhance his overall quality of care.

Harmonizing Coordinated Care Results with Industry Best Practices

Ensuring patient outcomes and care coordination metrics align with professional standards guarantees that best practices are followed, thus improving the quality and effectiveness of patient care (Commons et al., 2022). For Mr. Decker, preventing readmission requires developing a detailed treatment plan, providing comprehensive education about his health issues, and creating a well-defined subsequent care plan. This method adheres to the guidelines set by respected organizations such as CMS, which use hospital return rates as a key indicator of care quality.

Professional organizations such as the American Association of Clinical Endocrinologists (AACE) establish guidelines for managing chronic illnesses such as diabetes (Colvin et al., 2023). These guidelines encompass routine blood glucose monitoring, effective medication management, and necessary lifestyle changes. Coordinating Mr. Decker’s treatment to ensure compliance with these recommendations is essential for managing his diabetes effectively. Patient satisfaction is a key component of professional standards. Tools like the HCAHPS survey measure the aspect of healthcare delivery, and healthcare providers strive to improve their scores on surveys to enhance overall care quality (Pasquel et al., 2021). By adhering to these standards, healthcare providers improve Mr. Decker’s health results and the healthcare system’s overall standard.

Determining Critical Evidence-based Strategies for Optimal Population Health Management

Implementing a successful plan of care for Mr. Decker from a population health perspective requires the integration of evidence-based practices drawn from current and credible sources. Effective care coordination practices are vital for improving patient outcomes and managing population health efficiently (Colvin et al., 2023). For Mr. Decker, utilizing patient-centered medical homes (PCMHs) can be highly beneficial. PCMHs provide comprehensive, coordinated care through a team-based approach, ensuring continuous, accessible, and family-centered care. Research by Xie et al. (2021) indicates that PCMHs improve care quality and patient satisfaction and reduce healthcare costs by focusing on preventive care and chronic disease management. This model can address Mr. Decker’s chronic diabetes and other health concerns effectively, ensuring he receives holistic and continuous care.

Another essential practice for Mr. Decker’s care is the implementation of health information technology systems, i.e., EHRs. EHRs facilitate the sharing of Mr. Decker’s health information among healthcare providers, improving communication, reducing errors, and enhancing care coordination. Research by Upadhyay & Hu (2022) has shown that using EHRs leads to better patient outcomes and more efficient healthcare delivery. By ensuring that all relevant health data is accessible, Mr. Decker’s care team can make informed decisions quickly and accurately.

Care transition programs are also critical for Mr. Decker, especially given his recent hospital readmission due to sepsis. These programs ensure continuity of care, patient education, and follow-up, reducing readmissions and improving health outcomes. A study by Shah et al. (2022) demonstrates that structured care transition interventions, such as the Care Transitions Intervention (CTI), significantly decrease hospital readmissions and enhance patient satisfaction. Implementing such a program for Mr. Decker can ensure he understands his care plan and receives the necessary support during transitions between care settings.

Employing community health workers (CHWs) can enhance care coordination for Mr. Decker. CHWs, who often share cultural and social backgrounds with the populations they serve, can improve access to care, provide education, and support chronic disease management. Research by Killough et al. (2023) supports the effectiveness of CHWs in improving health outcomes and reducing healthcare disparities. For Mr. Decker, a CHW could provide personalized support, helping him manage his diabetes and navigate the healthcare system. Integrating evidence-based practices allows Mr. Decker’s healthcare providers to develop a thorough care plan that improves his health and overall well-being.

Benefits of a Collaborative Strategy in Care Coordination

Promoting collaborative medical care is essential for effectively addressing immediate and long-term health needs (Duru et al., 2020). For patients like Mr. Decker, collaboration among specialists, including endocrinologists, infectious disease experts, pharmacists, nurses, and social workers, is imperative. This teamwork integrates diverse perspectives and resources, significantly enhancing patient outcomes. A study by  Korytkowski et al. (2020) suggests that a multidisciplinary team can minimize medical mistakes, boost safety, and elevate the quality of care. Integrating all elements of care, i.e., from emergency treatment to post-discharge follow-up and sustained long-term care of conditions like diabetes—a multidisciplinary approach ensures continuity of care, a critical factor in improving health outcomes for patients with complex medical conditions. This collaborative model supports seamless transitions between different stages of care and incorporates various therapeutic viewpoints, leading to more effective and comprehensive treatment outcomes. Research by Srinivas et al. (2023) has shown that patients receiving coordinated care from multidisciplinary teams experience better health outcomes, lower hospital readmission rates, and higher satisfaction levels. Thus, advocating for a multidisciplinary approach is crucial for fostering a healthcare environment prioritizing comprehensive, focused care, resulting in better health results and greater patient contentment. 

NURS FPX Assessment 1: Comprehensive Needs Assessment Conclusion

A multidisciplinary approach to patient care is pivotal for addressing patients’ complex and varied health needs, like Mr. Decker’s. By fostering collaboration among a diverse team of healthcare professionals, the multidisciplinary model ensures comprehensive, coordinated care that improves patient outcomes, reduces readmissions, and enhances patient satisfaction (Commons et al., 2022). This analysis points out several interconnected elements, aging, diabetes, social support networks, and economic factors that are vital for ensuring high-quality patient care. It describes holistic, evidence-based approaches to managing sepsis efficiently. Furthermore, it strongly endorses a team-based approach to care coordination, backed by research, to enhance the effectiveness of patient care plans. This approach integrates diverse therapeutic perspectives, improving health outcomes and patient satisfaction.

NURS FPX Assessment 1: Comprehensive Needs Assessment References

Buléon, C., Mattatia, L., & Minehart, R.D. (2022). Simulation-based summative assessment in healthcare: An overview of key principles for practice. Advances in Simulation, 7, 42. https://doi.org/10.1186/s41077-022-00238-9 

Colvin, C. L., Akinyelure, O. P., Rajan, M., Safford, M. M., Carson, A. P., Muntner, P., Colantonio, L. D., & Kern, L. M. (2023). Diabetes, gaps in care coordination, and preventable adverse events. The American Journal of Managed Care, 29(6), e162–e168. https://doi.org/10.37765/ajmc.2023.89374 

Commons, R. J., Charles, J., Cheney, J. (2022). Australian guideline on management of diabetes-related foot infection: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. Journal of Foot and Ankle Research, 15, 47. https://doi.org/10.1186/s13047-022-00545-4 

Duru, O. K., Harwood, J., Moin, T., Jackson, N. J., Ettner, S. L., Vasilyev, A., Mosley, D. G., O’Shea, D. L., Ho, S., & Mangione, C. M. (2020). Evaluation of a national care coordination program to reduce utilization among high-cost, high-need medicaid beneficiaries with diabetes. Medical Care, S14–S21. https://doi.org/10.1097/MLR.0000000000001315 

Islam, K. R., Prithula, J., Kumar, J., Tan, T. L., Reaz, M. B. I., Sumon, M. S. I., & Chowdhury, M. E. H. (2023). Machine learning-based early prediction of sepsis using electronic health records: A systematic review. Journal of Clinical Medicine, 12(17), 5658. https://doi.org/10.3390/jcm12175658 

Kao, S. L., Chen, Y., Ning, Y., Tan, M., Salloway, M., Khoo, E. Y. H., Tai, E. S., & Tan, C. S. (2020). Evaluating the effectiveness of a multi-faceted inpatient diabetes management program among hospitalized patients with diabetes mellitus. Clinical Diabetes and Endocrinology, 6(1), 21. https://doi.org/10.1186/s40842-020-00107-2 

Killough, C. M., Madaras, A., Phillips, C., Hettema, J., Ceballos, V., Fuentes, J. E., Rishel Brakey, H., Wagner, K., & Page, K. (2023). Community health worker insights on promoting research engagement with diverse populations. Frontiers in Public Health, 10, 959504. https://doi.org/10.3389/fpubh.2022.959504 

Korytkowski, M., Antinori, K., Drincic, A., Hirsch, I. B., McDonnell, M. E., Rushakoff, R., & Muniyappa, R. (2020). A pragmatic approach to inpatient diabetes management during the COVID-19 pandemic. The Journal of Clinical Endocrinology and Metabolism, 105(9), dgaa342. https://doi.org/10.1210/clinem/dgaa342 

Luconi, F., Montoro, R., Lalla, L., & Teferra, M. (2022). An innovative needs assessment approach to develop relevant continuing professional development for psychiatrists. Academic Psychiatry, 46(1), 106–113. https://doi.org/10.1007/s40596-021-01564-2 

Pasquel, F. J., Lansang, M. C., Dhatariya, K., & Umpierrez, G. E. (2021). Management of diabetes and hyperglycemia in the hospital. Diabetes & Endocrinology, 9(3), 174–188. https://doi.org/10.1016/S2213-8587(20)30381-8 

Shah, M. N., Jacobsohn, G. C., Jones, C. M., Green, R. K., Caprio, T. V., Cochran, A. L., Cushman, J. T., Lohmeier, M., & Kind, A. J. H. (2022). Care transition intervention reduces ED revisits in cognitively impaired patients. Alzheimer’s & Dementia, 8(1), e12261. https://doi.org/10.1002/trc2.12261 

Srinivas, V., Choubey, U., Motwani, J., Anamika, F., Chennupati, C., Garg, N., Gupta, V., & Jain, R. (2023). Synergistic strategies: Optimizing outcomes through a multidisciplinary approach to clinical rounds. Proceedings, 37(1), 144–150. https://doi.org/10.1080/08998280.2023.2274230 

Upadhyay, S., & Hu, H. F. (2022). A qualitative analysis of the impact of electronic health records (EHR) on healthcare quality and safety: Clinicians’ lived experiences. Health Services Insights, 15, 11786329211070722. https://doi.org/10.1177/11786329211070722 

Xie, Z., Yadav, S., Larson, S. A., Mainous, A. G., & Hong, Y. R. (2021). Associations of patient-centered medical home with quality of care, patient experience, and health expenditures: A STROBE-compliant cross-sectional study. Medicine, 100(21), e26119. https://doi.org/10.1097/MD.0000000000026119 

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