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NURS FPX 6614 Assessment 1 Defining a Gap in Practice: Executive Summary

Assessment 1: Defining a Gap in Practice: Executive Summary


Capella University

Structure and Process in Care Coordination

Instructor Name

June 27th, 2024

Defining a Gap in Practice: Executive Summary

Coordinated care is an essential aspect of healthcare, focusing on systematically organizing patient care tasks and ensuring that information is effectively communicated among all involved healthcare providers to promote safer and more efficient care delivery (Khanna et al., 2022). This process aims to enhance the overall quality of patient care by facilitating seamless interactions and collaborations among various healthcare professionals. This assessment identifies a gap in current care coordination practices. It formulates a PICOT question to address it, aiming to improve health outcomes for a specific patient population at various levels. The summary provides decision-makers with key information on clinical priorities, available resources, suitable interventions, and expected outcomes, offering a comprehensive plan to enhance care coordination and patient outcomes.

Analyzing Clinical Priorities for Effective Care Coordination

Care coordination is vital for organizing patient care and ensuring effective communication among providers to improve outcomes, particularly for elderly patients with chronic illnesses (Aboumatar et al., 2022). Key priorities include managing multiple medications, preventing readmissions, and addressing comorbid conditions. Proper medication management and monitoring can reduce adverse events and hospitalizations. Improving care coordination involves identifying information gaps, analyzing patient adherence, and comparing care models to find the most effective approach (Wang et al., 2024). Social determinants, patient engagement, and teamwork are crucial for tailored care coordination, ultimately enhancing health outcomes and resource efficiency (Emadi et al., 2022). 

Identifying Areas for Improvement with a PICOT Question

The PICOT question designed to tackle discrepancy in care management for senior individuals with long-term health conditions is: In elderly patients with chronic conditions (P), how does a holistic service management initiative (I) compared to conventional care approaches (C) influence hospital readmission rates (O) within six months (T)? Seniors with chronic health issues frequently encounter disjointed treatment, resulting in numerous hospital returns. The lack of integration and coordination among healthcare providers creates a significant gap in current practices, leading to inconsistent chronic conditions and medication management. Research by Jika et al. (2021) found that a comprehensive care coordination program can improve continuity of care, enhance provider communication, and ensure consistent patient monitoring. Aboumatar et al. (2022) indicate that poor care coordination leads to negative patient outcomes and higher healthcare costs due to increased readmission rates. Implementing comprehensive care coordination programs can address these issues by providing structured, integrated care. Research by Khatri et al. (2023) supports this approach, showing significant reductions in readmissions and improvements in medication adherence and patient satisfaction, advocating for such programs to improve patient care and reduce expenses.

Evaluating Possible Solutions and Support for Care Management

Multiple sources enhance care coordination for older adults with chronic illnesses. These include electronic health records (EHRs) for information sharing, home healthcare services for medical and daily assistance, and telehealth services for remote monitoring and consultations. Aboumatar et al.(2022) found that care coordination programs use case managers who help manage care plans, schedule appointments, and ensure treatment adherence. Research by Kvarnström et al. (2021) demonstrates that significant barriers limit the effective use of these resources, including the lack of interoperability between different EHR systems, technological barriers, patients’ lack of digital literacy, and financial constraints, as not all services are covered by insurance. Research by Zhang & Saltman (2022) highlights the benefits and challenges, such as the need for interoperable EHRs, robust telehealth infrastructure, and patient education. Addressing these barriers through policy changes, technological improvements, and patient support is crucial for optimizing elderly care services and improving health outcomes.

Assessing the Best Care Coordination Intervention

The most effective strategy for coordinating care for elderly patients with long-term health conditions is a comprehensive care coordination program (Li et al., 2021). This program should involve interdisciplinary groups composed of doctors, healthcare practitioners, social care providers, and pharmacists and use advanced EHRs for seamless information sharing and telehealth for continuous monitoring. Key components include regular interdisciplinary meetings, dedicated care coordinators for personalized follow-up, and patient and family education on chronic condition management and medication adherence. Securing funding through insurance reforms and grants can address financial barriers. Research by Li et al. (2021) shows these integrated approaches significantly reduce hospital readmissions and improve health outcomes.

Summarizing the Selected Nursing Diagnosis

The nursing diagnosis “Ineffective Health Maintenance related to complex medication regimen and multiple chronic conditions” supports a collaborative care approach for elderly patients with chronic illnesses (Kvarnström et al., 2021). Effective strategies include interdisciplinary care plans, advanced EHRs for information sharing, patient education for self-management, regular follow-ups, and telehealth services for continuous care. Involving family members can enhance adherence and outcomes (Wang et al., 2024). These practices improve stakeholder commitment and patient outcomes through coordinated, evidence-based care, effectively aligning team efforts and resources.

Planning the Intervention and Expected Outcomes

The intervention planning involves creating an interdisciplinary care team, developing comprehensive care plans, and using advanced EHR systems for seamless communication (Emadi et al., 2022). It includes regular team meetings and patient education sessions. Expected outcomes are better medication adherence, fewer hospital readmissions, and higher patient satisfaction. These steps align with best practices for holistic, patient-centered care coordination. Key assumptions are the availability of technology and engagement from patients and providers (Schwarz et al., 2022). To improve outcomes, it is recommended that funding be secured for technology upgrades and continuous training for care team members.

NURS FPX 6614 Assessment 1 Defining a Gap in Practice: Executive Summary Conclusion

Addressing the discrepancy in service integration for seniors with long-term health conditions through a holistic service management initiative is essential for improving health outcomes (Khatri et al., 2023). Integrating multidisciplinary teams, utilizing advanced EHRs, and providing continuous patient education and monitoring can significantly reduce hospital readmissions and enhance patient satisfaction. Overcoming barriers such as technological challenges and financial constraints through policy changes and support programs is crucial (Khanna et al., 2022). These efforts will optimize care coordination and align with evidence-based practices, ensuring holistic, patient-centered care. Implementing these strategies will ultimately lead to better health outcomes and more efficient healthcare delivery for this vulnerable population.

NURS FPX 6614 Assessment 1 Defining a Gap in Practice: Executive Summary References

Aboumatar, H., Pitts, S., Sharma, R., Das, A., Smith, B. M., Day, J., Holzhauer, K., Yang, S., Bass, E. B., & Bennett, W. L. (2022). Patient engagement strategies for adults with chronic conditions: An evidence map. Systematic Reviews, 11(1), 39. 

Donneyong, M. M., Bynum, M., Kemavor, A., Crossnohere, N. L., Schuster, A., & Bridges, J. (2024). Patient satisfaction with the quality of care received is associated with adherence to antidepressant medications. PloS One, 19(1), e0296062. 

Emadi, F., Ghanbarzadegan, A., Ghahramani, S., Bastani, P., & Baysari, M. T. (2022). Factors affecting medication adherence among older adults using tele-pharmacy services: A scoping review. Archives of Public Health, 80(1), 199. 

Jika, B. M., Khan, H. T. A., & Lawal, M. (2021). Exploring experiences of family caregivers for older adults with chronic illness: A scoping review. Geriatric Nursing, 42(6), 1525–1532. 

Khanna, A., Fix, G. M., Anderson, E., Bolton, R. E., Bokhour, B. G., Foster, M., Smith, J. G., & Vimalananda, V. G. (2022). Towards a framework for patient-centered care coordination: A scoping review protocol. BMJ Open, 12(12), e066808. 

Khatri, R., Endalamaw, A., Erku, D., Wolka, E., Nigatu, F., Zewdie, A., & Assefa, Y. (2023). Continuity and care coordination of primary health care: A scoping review. Health Services Research, 23(1), 750. 

Kvarnström, K., Westerholm, A., Airaksinen, M., & Liira, H. (2021). Factors contributing to medication adherence in patients with a chronic condition: A scoping review of qualitative research. Pharmaceutics, 13(7), 1100. 

Li, E., Clarke, J., Neves, A. L., Ashrafian, H., & Darzi, A. (2021). Electronic health records, interoperability and patient safety in health systems of high-income countries: A  systematic review protocol. Health Informatics, 11(7), e044941. 

Schwarz, T., Schmidt, A. E., Bobek, J., & Ladurner, J. (2022). Barriers to accessing health care for people with chronic conditions: A qualitative interview study. Health Services Research, 22(1), 1037. 

Wang, Y., Leo, L., Vander, B., Davis, K., Gill, T. M., & Becher, R. D. (2024). National estimates of short- and longer-term hospital readmissions after major surgery among community-living older adults. JAMA Network Open, 7(2), e240028. 

Zhang, X., & Saltman, R. (2022). Impact of electronic health record interoperability on telehealth service outcomes. JMIR Medical Informatics, 10(1), e31837. 

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