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NURS FPX 6614 Assessment 3 Disseminating the Evidence Scholarly Video Media

Assessment 3: Disseminating the Evidence Scholarly Video Media 


Capella University

Structure and Process in Care Coordination

Instructor Name

June, 2024

Disseminating the Evidence Scholarly Video Media

Hello, I am ___________, and today, I will discuss my care coordination intervention, focusing on enhancing outcomes through interprofessional collaboration and evidence-based practices. This intervention sought to fill the identified service gap of elderly patients with chronic conditions through a service management approach. In describing care coordination in this video, I will first identify and discuss the care coordination attempts. Secondly, I will explain the shifts in practice and discuss the approaches used to foster the engagement of the stakeholders. Through effective leadership and stakeholder engagement, the project improved patient satisfaction, reduced hospital readmissions, and enhanced medication adherence, aiming to inspire better care coordination initiatives. 

Care Coordination Efforts and PICOT Analysis

The PICOT question guiding the project was: 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)? The first problem identified is focused on the unresolved concerns regarding the readmissions of elderly chronic patients and the ineffectiveness of their care coordination. Selecting a major service management initiative that envisages the provision of integrated and efficient patient care is an applicable approach. The breakdown of the consequences of this approach showed that it significantly helped decrease the number of recurrent readmissions to the hospital and compliance with medication regimens. Some of the critical considerations are the enhanced meaning use, interdisciplinary cooperation, and the application of enhanced EHR. Research by Bhati et al. (2023) has backed the efficiency of CCC in enhancing patient health status and diminishing the readmission rate. Furthermore, A study by Jika et al. (2021) emphasizes the need to monitor the patient status and maintain the provider’s communication. The data strengthens how structured and integrated care coordination enhances the health of elderly chronic patients and fulfills their end-user satisfaction, according to engaging the stakeholders and monitoring the process persistently.

Overview of Changes in Practice

The change in practice implied implementing an integrated service management plan to redefine the elderly patient suffering from chronic disorders care (Emadi et al., 2022). Thus, utilizing this approach, enhancing the coordinated consumption of the services and resources in the interprofessional care coordination team was possible. Specific to the model, individual ones included the modern and integrated EHRs and the daily/weekly interdisciplinary team conferences. As stated by Marzban et al. (2022), the stakeholders’ engagement in the patient’s care reduces the hospitalization rate and medication adherence among the patients. Research by Bornman & Louw (2023) highlighted that the initiative was centered on patient and family participation for better self-management and compliance with prescribed regimes. The changes were implemented to enhance integrated and effective care delivery to clients, and the nursing staff agreed. This evidence-based practice change also highlights the need for well-organized, systematic care delivery and resource managerialism to improve patient’s well-being and the overall quality of patients’ experience with healthcare services. 

Building Stakeholder Engagement

Strategies aimed at enhancing the stakeholders’ involvement in the interprofessional team were emphasized on themes such as shared information and communication, as well as shared decision-making and feedback processes (Geese & Schmitt, 2023). The implementation of change in practice needed to occur through initiating and participating in weekly meetings with each discipline to review patients’ care plans to ensure roles and responsibilities were clear and to address any areas of confusion (Khanna et al., 2022). Another key strategy was implementing higher-level EHR systems for information exchange and providing seminars for raising stakeholders’ awareness of integrated care. Based on research by Pugh et al. (2021), information on success stories and enhanced patient outcomes was shared to promote encouragement. Engendering objectives of tolerance and co-workers’ cooperation tended to establish the integration of the team’s activities. Periodic meetings, feedback, and even open forums allowed them to air their grievances and competent ideas; thus, nobody could be complacent. This approach also helped to achieve the primary objectives of constructing sustainable paradigms of change, specifically new practices adoption and continual process improvement as well as satisfaction with the stakeholders.

Next Steps for Sustaining Care Coordination Outcomes

For the continuity of the results obtained from the coordinated care interprofessional team in the future, the future steps will involve the organizational training of all the team members to ensure that they are acquainted with the best practices and technologies available in the field. Interdisciplinary meetings should still be held regularly, and any arising matters must be discussed. To draw efficient knowledge for proper and concise medical care, research by Li et al. (2021) has described the effective ways of using properly advanced EHR systems through which important data shares and patient monitoring can be made. Also, a study by Zhang & Saltman  (2022) pointed out that integrating telehealth services can give a patient a regular support system and help cut the hospital’s readmission rate. A feedback mechanism will enable the continual assessment of the success and fast adaptation to complications. Maintaining a safe environment entails working within clinical standard procedures, focusing on periodic safety checkups (Khanna et al., 2022). Possible solutions for future actions include requesting funding to upgrade proper technologies and campaigning for changes in the legislation to encourage integrated care approaches. This fact-based and well-articulated plan of action also integrates a solid foundation for enhancing the ongoing nature of patients’ clinical quality and appropriate resource optimization, thereby developing a safe and effective care coordination system.

NURS FPX 6614 Assessment 3 Disseminating the Evidence Scholarly Video Media Conclusion

The care coordination intervention provided objective results of improved patient outcomes due to better cooperation and the implementation of empirical knowledge in practice (Marzban et al., 2022). The main objective of a thorough service delivery enhancement strategy was to lower the likelihood of readmissions amongst elderly patients with chronic diseases and make them adhere to their physician-prescribed regimes strictly (Geese & Schmitt, 2023). Therefore, for these outcomes to be maintained it requires regular engagement, evaluation, and effective management of the stakeholders’ involvement and resources. It also emphasizes better-integrated care coordination practices to enhance the rate of patients’ affairs and stimulate other healthcare organizations to adopt safer and more efficient treatment.

NURS FPX 6614 Assessment 3 Disseminating the Evidence Scholarly Video Media References

Bhati, D., Deogade, M. S., & Kanyal, D. (2023). Improving patient outcomes through effective hospital administration: A comprehensive review. Cureus, 15(10), e47731. 

Bornman, J., & Louw, B. (2023). Leadership development strategies in interprofessional healthcare collaboration: A rapid review. Journal of Healthcare Leadership, 15, 175–192. 

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. 

Geese, F., & Schmitt, K. U. (2023). Interprofessional collaboration in complex patient care transition: A qualitative multi-perspective analysis. Healthcare, 11(3), 359. 

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. 

Pugh, J., Penney, L. S., Noël, P. H., Neller, S., Mader, M., Finley, E. P., Lanham, H. J., & Leykum, L. (2021). Evidence-based processes to prevent readmissions: More is better, a ten-site observational study. BMC Health Services Research, 21(1), 189. 

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. 

Marzban, S., Najafi, M., Agolli, A., & Ashrafi, E. (2022). Impact of patient engagement on healthcare quality: A scoping review. Journal of Patient Experience, 9, 23743735221125439. 

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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