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NURS FPX 6610 Assessment 4 Case Presentation

Assessment 4: Case Presentation

Name

Capella University

Introduction to Care Coordination  

Instructor Name

June 26th, 2024

Slide 2

Case Presentation

Hi, Everyone. I am _________. In today’s presentation, I will discuss the complex care coordination required for managing Mrs. Snyder’s healthcare needs. Mrs. Snyder, a 76-year-old patient, is battling stage 4 ovarian cancer alongside chronic conditions such as type 2 diabetes, obesity, hypertension, and hypercholesterolemia. Managing her chronic pain and stress through specialist consultations and physical therapy, along with education on her conditions, is crucial to enhancing her quality of life and supporting her family.

Slide 4

Stakeholder Engagement in Patient Health and Safety

Stakeholders ensure patient health and safety by advocating for and executing care plans (Ferreira et al., 2023). Their participation is essential in developing a comprehensive approach that addresses multiple facets of healthcare. In the context of Mrs. Snyder’s care, the collaborative efforts of an interprofessional team, including primary care physicians, nurse practitioners, dietitians, pharmacists, physical therapists, social workers, and spiritual care advisors, are essential. Each stakeholder brings a unique perspective and expertise, ensuring that all aspects of her health are addressed comprehensively (Hoffman & Cowdery, 2021). It includes her medical needs and her psychological, social, and spiritual well-being. By working together, these stakeholders ensure that the care plan is responsive and tailored to Mrs. Snyder’s specific health requirements, ultimately enhancing the quality and safety of her care.

Slide 5

Involvement of Stakeholders in Patient Health

Healthcare professionals, relatives, social service workers, and community groups greatly improve patient health by providing varied viewpoints and expert skills (Hui & Bruera, 2020). In healthcare environments, stakeholders work together to ensure every aspect of a patient’s well-being is managed, from initial assessment through treatment and follow-up care (Huber, 2022). This collaborative approach enhances the responsiveness and alignment of the care plan with the patient’s particular medical requirements. 

Improving Safety through Collaborative Stakeholder Efforts

Active participation from stakeholders guarantees safe, effective care, addressing complex health needs collaboratively (Moecker et al., 2022). By working together, all aspects of patient care are managed efficiently, leading to better health outcomes and increased safety (Lee et al., 2023). This approach is crucial for managing Mrs. Snyder’s complex health conditions.

Slide 6

Components of Ongoing Care

Ongoing care entails a comprehensive strategy that necessitates continual assessment and modification to address the changing needs of patients, particularly those with chronic or life-threatening conditions (Reinders & Krijnen, 2023). This care approach emphasizes sustaining patient health and quality of life over the long term by incorporating diverse components that contribute to effective and customized treatment plans.

Recognizing Key Factors

A key aspect of ongoing care is recognizing the various factors that can influence patient outcomes (Wei et al., 2020). For Mrs. Snyder, these factors include medical aspects such as the progression of her stage 4 ovarian cancer, type 2 diabetes, hypertension, obesity, and hypercholesterolemia. Psychological factors, such as emotional response to illness and motivation to adhere to treatment, also play a significant role (Reinders & Krijnen, 2023).  Socioeconomic factors, including her access to healthcare services, insurance coverage, and family support, are crucial in shaping her care plan (Mohammed et al., 2021).  Environmental factors, such as the safety and accessibility of her living conditions, further influence health outcomes (Moecker et al., 2022). Recognizing these influences allows healthcare providers to tailor interventions that address Mrs. Snyder’s specific challenges. For instance, a personalized exercise program and regular visits from a dietitian can help manage her diabetes and obesity. At the same time, a social worker can assist in navigating healthcare services and financial support.

Forming Conclusions and Recognizing Uncertainties

The ongoing assessment of these components enables healthcare teams to derive insightful and logical conclusions regarding the most effective strategies for Mrs. Snyder’s treatment. If she doesn’t respond to treatment as expected, providers may need to alternate therapies or check for compliance issues. Recognizing underlying assumptions and uncertainties (Moecker et al., 2022). For instance, a care strategy based on standard disease progression assumptions might require modifications if Mrs. Snyder exhibits unusual symptoms or reactions. Acknowledging these uncertainties and preparing for different scenarios aids in developing a more flexible and robust care plan. This method improves the quality of care and bolsters Mrs. Snyder’s overall well-being through carefully tailored interventions.

Slide 7

Evaluation of the Patient

At 76, Mrs. Snyder faces a complex medical situation with multiple chronic illnesses and a severe cancer diagnosis. She has long-term issues with poorly managed type 2 diabetes and obesity, along with hypertension and hypercholesterolemia, increasing her cardiovascular risk. Her stage 4 ovarian cancer has shifted the treatment focus to palliative care, aiming to enhance her quality of life and relieve symptoms. Her care is further complicated by dietary restrictions, religious practices, and cultural values, necessitating a personalized care plan. A multidisciplinary team approach is essential to manage her physical symptoms and support her overall well-being.

Slide 8

Interprofessional Care Team and High-Quality Patient Outcomes

A multidisciplinary care team provides superior-quality patient outcomes by combining the specialized expertise of various healthcare professionals to address all aspects of a patient’s needs comprehensively (Moecker et al., 2022). Mrs. Snyder’s interprofessional care team collaborates to deliver comprehensive care. The primary care doctors manage her overall medical treatment, while nurse practitioners provide direct care, monitor her vital signs, and manage her medications. Dietitians develop personalized nutrition plans to manage her diabetes, hypertension, and obesity. Pharmacists ensure medication reconciliation, monitor for drug interactions, and educate her on proper medication usage. Physical therapists design and supervise exercise programs to improve her mobility and reduce pain. Social workers offer psychosocial support, assist with navigating healthcare services, and connect her with community resources. Credible evidence supports that interprofessional collaboration in healthcare settings significantly improves patient outcomes.

For instance, coordinated care teams improve patient satisfaction and reduce hospital readmissions (Ansa et al., 2020). This holistic approach meets the informational needs of various stakeholders, including patients, families, and healthcare providers, ensuring they are well-informed and engaged in the care process. By addressing Mrs. Snyder’s diverse needs through a coordinated effort, the interprofessional care team can effectively manage her complex health conditions and improve her overall quality of life.

Slide 9

Factors Affecting Patient Outcomes

When assessing patient outcomes in complex cases like Mrs. Snyder’s, it is essential to consider various factors, including medical, psychological, social, environmental, and spiritual aspects. Mrs. Snyder’s conditions, such as stage 4 ovarian cancer, type 2 diabetes, obesity, hypertension, and hypercholesterolemia, require a coordinated treatment approach. Psychological stress and emotional responses significantly impact her health, while support from family, friends, and healthcare providers is crucial for morale and treatment adherence. Environmental accessibility, spiritual needs, and financial considerations like insurance and treatment affordability are also vital. A holistic and coordinated care plan addressing these elements is essential for improving her quality of life, considering all assumptions and uncertainties to achieve the best outcomes. A holistic and coordinated care plan addressing medical, psychological, social, environmental, and spiritual aspects, alongside financial considerations, is essential for improving Mrs. Snyder’s quality of life and achieving the best possible outcomes.

Slide 10: 

Presumptions

Considering possible deviations from anticipated patterns, assumptions about Mrs. Snyder’s reaction to treatments, the strength of her support system, her access to healthcare resources, and her cognitive capabilities are essential.

Uncertain Factors

The advancement of Mrs. Snyder’s cancer introduces unpredictability to her care plan. The efficacy of symptom control, the level of family support, and her emotional health are also uncertain factors. Therefore, a highly individualized and flexible approach is crucial to ensure her care stays focused on the patient and offers her the best possible quality of life given the circumstances (Reinders & Krijnen, 2023).

Slide 11

Resources Needed to Implement Continuing Care

Implementing continuing care for Mrs. Snyder requires comprehensive resources tailored to her complex medical and personal needs. Several factors influence the determination of these resources, including the severity of her condition, her ability to adhere to treatment plans, and the available support systems.

Medical Resources

Mrs. Snyder needs regular medical monitoring and management due to her stage 4 ovarian cancer, type 2 diabetes, obesity, hypertension, and hypercholesterolemia. This includes frequent visits to her primary care physician and oncologist, regular blood tests, imaging studies, and management of her medications. Access to a palliative care specialist is also essential to manage her symptoms and improve her quality of life. A diabetes educator must manage her blood sugar levels and implement dietary changes (Huber, 2022). 

Supportive Services

Supportive services such as home healthcare are crucial for Mrs. Snyder. This includes nursing care for medication administration and monitoring of her vital signs, as well as physical therapy to help maintain her mobility and manage pain. Nutritional counseling by a dietitian is vital to help her manage her diabetes and obesity (Huber, 2022). A social worker can coordinate care, provide emotional support, and connect her with community resources and financial assistance programs.

Psychosocial and Spiritual Support

Psychosocial support is important for addressing Mrs. Snyder’s mental health needs, including counseling or therapy to manage anxiety and depression related to her illness. Spiritual care advisors can provide comfort and support aligned with her faith and religious practices, which are crucial for the patient’s well-being (Huber, 2022).

Slide 12 

Technological Resources

Technological resources such as telemedicine services can enhance her access to healthcare providers, especially if she has mobility issues or lives far from healthcare facilities. Remote monitoring tools for her diabetes and blood pressure can help manage her conditions more effectively (Moecker et al., 2022).

Justification of Assertions

These resources are justified based on Mrs. Snyder’s multifaceted health needs. Regular medical oversight ensures that her complex conditions are closely monitored and managed, reducing the risk of complications. Home healthcare services provide convenience and ensure continuity of care, essential for patients with mobility challenges and multiple chronic conditions. Psychosocial and spiritual support address the emotional and mental health aspects of care, which are equally important for maintaining quality of life (Moecker et al., 2022). Telemedicine and remote monitoring tools increase accessibility and allow timely interventions, crucial for managing chronic conditions effectively (Lee et al., 2023).

Considering all these elements, an extensive and well-organized care plan can be implemented, guaranteeing that Mrs. Snyder receives the essential support to manage her health issues and sustain her quality of life.

Slide 13

NURS FPX 6610 Assessment 4 Case Presentation: Conclusion

In conclusion, the care coordination for Mrs. Snyder requires a comprehensive and multidisciplinary approach to effectively manage her complex medical conditions and enhance her quality of life. We can address her medical, psychological, social, and spiritual needs by focusing on seamless transitions, stakeholder engagement, and continuous evaluation. Implementing a personalized care plan, supported by an interprofessional team, ensures that Mrs. Snyder receives the best possible care. This holistic approach improves her health outcomes and supports her and her family during this challenging time.

NURS FPX 6610 Assessment 4 Case Presentation: References

Ansa, B. E., Zechariah, S., Gates, A. M., Johnson, S. W., Heboyan, V., & De Leo, G. (2020). Attitudes and behavior towards interprofessional collaboration among healthcare professionals in a large academic medical center. Healthcare, 8(3), 323. https://doi.org/10.3390/healthcare8030323

Bosveld, M. H., Romme, S., de Nooijer, J., Smeets, H. W. H., van Dongen, J. J. J., & van Bokhoven, M. A. (2023). Seeing the patient as a person in interprofessional health professions education. Journal of Interprofessional Care, 37(3), 457–463. https://doi.org/10.1080/13561820.2022.2093843

Cai, S., Huang, X., Van, C., Li, W., Yan, M., Lu, Y., Li, H., Deng, Z., Lu, P., & Xu, Z. (2023). General practitioners’ attitudes towards and frequency of collaboration with pharmacists in China: A cross-sectional study. BMC Health Services Research, 23(1), 1174. https://doi.org/10.1186/s12913-023-10151-0

Ferreira, D. C., Vieira, I., Pedro, M. I., Caldas, P., & Varela, M. (2023). Patient satisfaction with healthcare services and the techniques used for its assessment: A systematic literature review and a bibliometric analysis. Healthcare, 11(5), 639. https://doi.org/10.3390/healthcare11050639

Hoffman, J. L., & Cowdery, J. E. (2021). Interprofessional collaboration in public health. Nursing Education Perspectives, 42(1), 46–48. https://doi.org/10.1097/01.NEP.0000000000000591

Hui, D., & Bruera, E. (2020). Models of palliative care delivery for patients with cancer. Journal of Clinical Oncology, 38(9), 852–865. https://doi.org/10.1200/JCO.18.02123

Huber, C. (2022). Interprofessional collaboration in health care. Praxis, 110(1), 3–4. https://doi.org/10.1024/1661-8157/a003808

Lee, Y. J., Chung, Y. S., Lee, J. Y., Nam, E. J., Kim, S. W., Kim, Y. T., & Kim, S. (2023). Role of diagnostic laparoscopy in deciding primary treatment in advanced-stage ovarian cancer. Journal of Gynecologic Oncology, 34(2), e17. https://doi.org/10.3802/jgo.2023.34.e17

Mohammed, C. A., Narsipur, S., Vasthare, R., Singla, N., Yan Ran, A. L., & Suryanarayana, J. P. (2021). Attitude towards shared learning activities and interprofessional education among dental students in South India. European Journal of Dental Education, 25(1), 159–167. https://doi.org/10.1111/eje.12586

Moecker, R., Fuchs, A., Haefeli, W. E., Weissenborn, M., & Seidling, H. M. (2022). Attitudes of non-participating general practitioners and community pharmacists towards interprofessional medication management in primary care: an interview study. International Journal of Clinical Pharmacy, 44(6), 1380–1393. https://doi.org/10.1007/s11096-022-01434-3

Reinders, J. J., & Krijnen, W. (2023). Interprofessional identity and motivation towards interprofessional collaboration. Medical Education, 57(11), 1068–1078. https://doi.org/10.1111/medu.15096

Wei, H., Corbett, R. W., Ray, J., & Wei, T. L. (2020). A culture of caring: the essence of healthcare interprofessional collaboration. Journal of Interprofessional Care, 34(3), 324–331. https://doi.org/10.1080/13561820.2019.1641476

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