Category: MSN

NURS FPX 6614 Assessment 2 Enhancing Performance as Collaborators in Care Name Capella university NURS-FPX 6614 Structure and Process in Care Coordination Prof. Name Date Enhancing Performance as Collaborators in Care Enhancing Interprofessional Collaboration for Chronic Heart Failure (CHF) Care Effective collaboration among healthcare professionals is crucial for optimizing patient outcomes in Chronic Heart Failure (CHF) care. CHF affects over 6.2 million adults in the United States and is a leading cause of hospitalization, particularly among older adults (Bhatnagar et al., 2022). The integration of interprofessional collaboration enhances coordination and communication among healthcare providers, ensuring comprehensive and patient-centered care. By fostering collaboration among cardiologists, nurses, dietitians, and pharmacists, a more holistic approach to CHF management can be achieved. To enhance interprofessional collaboration, it is essential to conduct a thorough assessment of current practices, identifying potential gaps in communication and care delivery. Establishing structured care frameworks and standardized procedures facilitates better coordination among team members (Raat et al., 2021). Additionally, electronic health records (EHRs) serve as a valuable tool for real-time information sharing, minimizing fragmentation in patient care. Continuous education and training are also fundamental in reinforcing teamwork, as ongoing learning initiatives equip healthcare providers with the necessary skills to collaborate effectively (McMahon et al., 2024). Educational Services, Digital Health Tools, and Support Resources Providing CHF patients with educational resources is vital for effective disease management. Programs like the American Heart Association’s (AHA) Heart Failure: A Guide for Patients and Their Families offer valuable insights on medication adherence and lifestyle modifications (Heidenreich et al., 2022). Similarly, the Living Well with Heart Failure workshop by the Heart Failure Society of America (HFSA) educates patients on symptom management, physical activity, and dietary adjustments (Clements et al., 2022). Digital health tools, such as mobile applications and telehealth platforms, further enhance CHF care. Applications like MyHeartCounts by Stanford Medicine and MyChart by Epic Systems enable patients to track symptoms, receive medication reminders, and access educational content, fostering greater engagement in self-care (Christle et al., 2020). Telehealth platforms, including Teladoc and Amwell, provide remote consultations, ensuring continuity of care for patients with mobility or transportation challenges (Yadav, 2024). Support groups and community health programs also play a crucial role in CHF management. Initiatives such as the Heart Failure Support Group by the National Heart, Lung, and Blood Institute (NHLBI) offer peer support and shared experiences for patients, while the Better Choices, Better Health program provides tailored resources like exercise classes and nutritional counseling (White-Williams et al., 2020). Moreover, ongoing training for healthcare professionals, such as the Heart Failure Symposium by the American College of Cardiology (ACC), ensures that providers stay informed about advancements in CHF care (Heidenreich et al., 2022). Ethical Considerations and Proposed Outcomes Adherence to ethical principles is fundamental in optimizing CHF care. The principles of beneficence, non-maleficence, justice, and autonomy guide patient-centered initiatives, such as the Heart Failure Transitional Care Program at the Cleveland Clinic, which prioritizes equitable access to care (Raat et al., 2021). Implementing structured care coordination models ensures that interventions are designed to improve patient well-being while minimizing harm. Programs addressing disparities in healthcare access, such as those developed by the American Heart Association, further support ethical CHF care (Heidenreich et al., 2022). The anticipated outcomes of enhanced interprofessional collaboration include reduced hospital readmissions, improved medication adherence, and greater patient self-management skills. Research indicates that structured communication protocols and regular team meetings contribute to better care coordination, ultimately leading to positive health outcomes (Kho et al., 2022). However, challenges such as varying levels of provider engagement and EHR integration must be addressed through ongoing training and feedback mechanisms. By fostering a culture of continuous improvement, interprofessional collaboration can be strengthened to enhance CHF management and patient quality of life. Table Format: Enhancing Performance in CHF Care Key Area Description Supporting References Interprofessional Collaboration Facilitates teamwork among healthcare providers, improving communication and coordination in CHF care. Raat et al. (2021) Assessment of Care Practices Identifies gaps in care coordination and communication among CHF care teams. McMahon et al. (2024) Structured Care Frameworks Defines roles and responsibilities for multidisciplinary teams to enhance clarity in CHF management. King-Dailey et al. (2022) Use of Electronic Health Records Supports real-time data sharing and reduces fragmentation in patient care. Yadav (2024) Education and Training Provides ongoing learning opportunities to strengthen interprofessional teamwork. White-Williams et al. (2020) Patient Education Resources Programs like AHA’s Heart Failure Guide and HFSA’s Living Well with Heart Failure offer education on CHF self-management. Heidenreich et al. (2022); Clements et al. (2022) Digital Health Tools Apps like MyHeartCounts and MyChart facilitate symptom tracking and patient engagement. Christle et al. (2020) Telehealth Services Platforms like Teladoc and Amwell enhance remote monitoring and virtual consultations for CHF patients. Yadav (2024) Support Groups & Community Programs Groups such as Heart Failure Support Group and Better Choices, Better Health provide peer support and lifestyle guidance. White-Williams et al. (2020) Ethical Considerations Ensures beneficence, non-maleficence, justice, and autonomy in CHF care. Raat et al. (2021) Improved Patient Outcomes Reduces hospital readmissions, enhances medication adherence, and promotes patient self-care. Kho et al. (2022) Challenges & Considerations Provider engagement and seamless EHR integration remain challenges in implementing collaborative CHF care. Yadav (2024) References Bhatnagar, R., Fonarow, G. C., Heidenreich, P. A., & Ziaeian, B. (2022). Expenditure on heart failure in the United States. JACC: Heart Failure, 10(8), 571–580. https://doi.org/10.1016/j.jchf.2022.05.006 Christle, J. W., Hershman, S. G., Torres Soto, J., & Ashley, E. A. (2020). Mobile health monitoring of cardiac status. Annual Review of Biomedical Data Science, 3(1), 243–263. https://doi.org/10.1146/annurev-biodatasci-030220-105124 Clements, L., Frazier, S. K., Lennie, T. A., Chung, M. L., & Moser, D. K. (2022). Improvement in heart failure self-care and patient readmissions with caregiver education: A randomized controlled trial. Western Journal of Nursing Research, 45(5), 019394592211412. https://doi.org/10.1177/01939459221141296 Heidenreich, P. A., et al. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure. Circulation, 145(18). https://doi.org/10.1161/cir.0000000000001063 Kho, A. N., et al. (2022). The National Heart Lung and Blood Institute disparities elimination through coordinated interventions. Health Services Research, 57(S1), 20–31. https://doi.org/10.1111/1475-6773.13983 NURS FPX 6614 Assessment 2 Enhancing Performance as Collaborators in Care McMahon, J., et al. (2024). Heart failure in nursing homes: A scoping review. International Journal of Nursing Studies Advances, 6, 100178. https://doi.org/10.1016/j.ijnsa.2024.100178 Raat, W., Smeets, M., Janssens, S., & Vaes, B. (2021). Impact of primary care

NURS FPX 6614 Assessment 1 Defining a Gap in Practice Name Capella university NURS-FPX 6614 Structure and Process in Care Coordination Prof. Name Date Defining a Gap in Practice: Executive Summary Chronic Heart Failure (CHF) presents major healthcare challenges, including high hospital readmission rates and insufficient post-discharge care. The death rate from heart disease rose by 4.1% in 2020 after years of decline (Woodruff et al., 2022). This paper proposes a nurse-led transitional care management program to address these issues and improve patient outcomes. Clinical Priorities for a Specific Population For adult CHF patients, key priorities include reducing hospital readmissions, managing symptoms, and enhancing quality of life. A nurse-led transitional care management program helps achieve these goals by focusing on discharge planning, patient education, and follow-up care (Li et al., 2021b). Effective care involves personalized plans, routine monitoring, and addressing socioeconomic barriers. Information gaps exist in patient education on self-management, while solutions such as telehealth and improved patient-family engagement may enhance outcomes. This strategy aims to improve patient health and reduce healthcare expenses (Apery & Oremus, 2022). PICOT Question The study’s PICOT question is: In adults with CHF in an ambulatory care setting (P), does a nurse-led intermediate care management program (I), compared to standard discharge (C), reduce 30-day hospital readmissions (O) within three months post-discharge (T)? The practice gap involves high CHF readmission rates due to inadequate post-discharge care. Standard discharge planning lacks essential follow-up and patient education, while a nurse-led program offers tailored care, ongoing monitoring, and better education (Apery & Oremus, 2022). Nationally, implementing these programs could reduce healthcare costs and enhance patient outcomes through standardized post-discharge care. Studies show that nurse-led interventions decrease 30-day readmissions while improving medication adherence and patient satisfaction (Ledwin & Lorenz, 2021). This intervention is crucial for optimizing patient care and reducing financial strain. Table: Defining a Gap in Practice Key Aspects Details Potential Services and Resources CHF patients in the U.S. benefit from resources like American Heart Association guidelines and Medicare’s Chronic Care Management (CCM) services (AHA, 2023; CMS, 2024). These improve discharge planning and care continuity. However, challenges include restricted access in underserved regions, inconsistent program execution, and limited patient engagement (Ledwin & Lorenz, 2021). Addressing these barriers is crucial for better care coordination. Type of Care Coordination Intervention A nurse-led intermediate care program effectively improves CHF patient outcomes. This approach includes structured discharge planning, personalized patient education, and follow-up. Strategies involve standardized handoff protocols, telehealth for continuous monitoring, and medication reconciliation (Li et al., 2021b). Integrating electronic health records enhances communication and patient tracking. This program bridges post-discharge care gaps, improves adherence, and reduces readmission rates (Oskouie et al., 2023). Planning and Expected Outcomes Implementing the nurse-led transitional care program involves patient needs assessment, customized care planning, and interdisciplinary coordination. Core components include patient education, symptom tracking, and medication management. Expected results are fewer 30-day readmissions, enhanced medication adherence, and better self-management (Li et al., 2021c). The intervention aligns with care coordination standards and improves overall patient satisfaction. Key assumptions include resource availability for telehealth education and team commitment. Continuous monitoring and adaptation ensure long-term success (Apery & Oremus, 2022). Conclusion A nurse-led transitional care management program is essential for addressing CHF patients’ post-discharge care needs. By focusing on structured education, monitoring, and follow-up, this approach reduces readmissions, enhances patient self-management, and improves healthcare outcomes. Ongoing program evaluation and adaptation will ensure sustained success. References AHA. (2023). American Heart Association. www.heart.org Apery, K., & Oremus, M. (2022). Efficacy of telehealth in integrated chronic disease management for older, multimorbid adults with heart failure: A systematic review. International Journal of Medical Informatics, 162. https://doi.org/10.1016/j.ijmedinf.2022.104756 Bews, H. J., Pilkey, J. L., Malik, A. A., & Tam, J. W. (2023). Alternatives to hospitalization: Adding the patient voice to advanced heart failure management. Canadian Journal of Cardiology, 5(6), 454–462. https://doi.org/10.1016/j.cjco.2023.03.014 CMS. (2024). Manage your chronic condition. www.cms.gov Ledwin, K. M., & Lorenz, R. (2021). The impact of nurse-led community-based models of care on hospital admission rates in heart failure patients: An integrative review. Heart & Lung, 50(5), 685–692. https://doi.org/10.1016/j.hrtlng.2021.03.079 Li, M., Yuan, L., Meng, Q., Li, Y., Tian, X., Liu, R., & Fang, J. (2021a). Effects of nurse-led transitional care interventions for patients with heart failure on healthcare utilization: A meta-analysis of randomized controlled trials. PLOS ONE, 16(12). https://doi.org/10.1371/journal.pone.0261300 NURS FPX 6614 Assessment 1 Defining a Gap in Practice Li, Y., Fang, J., Li, M., & Luo, B. (2021b). Effect of nurse-led hospital-to-home transitional care interventions on mortality and psychosocial outcomes in adults with heart failure: A meta-analysis. European Journal of Cardiovascular Nursing, 21(4), 307–317. https://doi.org/10.1093/eurjcn/zvab105 Li, Y., Fu, M. R., Fang, J., Zheng, H., & Luo, B. (2021c). The effectiveness of transitional care interventions for adult people with heart failure on patient-centered health outcomes: A systematic review and meta-analysis including dose-response relationship. International Journal of Nursing Studies, 117. https://doi.org/10.1016/j.ijnurstu.2021.103902 Oskouie, S., Michael, F., Whitelaw, S., Bozkurt, B., Fonarow, G. C., & G.C, H. (2023). A scoping review of heart failure transitional care quality indicators and outcomes for use in clinical care and research. European Journal of Heart Failure, 25(10), 1842–1848. https://doi.org/10.1002/ejhf.2955 Woodruff, R. C., Tong, X., Jackson, S., Loustalot, F., & Vaughan, A. S. (2022). Abstract 9853: Trends in national death rates from heart disease in the United States, 2010–2020. Circulation, 146(1). https://doi.org/10.1161/circ.146.suppl_1.9853 NURS FPX 6614 Assessment 1 Defining a Gap in Practice

NURS FPX 6612 Assessment 4 Cost Savings Analysis Name Capella university NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Cost Savings Analysis Care coordination refers to collaborating among various healthcare professionals to organize and implement patient care activities and sharing information to provide safe and effective patient-centered care. It is a crucial component of healthcare management that aims to ensure that patients receive appropriate care at the right time and in the right setting (CMS, n.d.). This assessment presents a cost-savings analysis for Miami Valley Hospital, where I work as a senior care coordinator. This report aims to identify the impact of care coordination using Health Information Technology (HIT) on augmenting cost effectiveness, improving patient outcomes, and enhancing the collection of evidence-based data to improve healthcare quality for the community.  Care Coordination and Cost-Effectiveness Health Information Technology (HIT) is vital in enhancing care coordination. Effective implementation of HIT can lead to coordinated sharing of patient information, leading to safe and effective patient care. Effective patient care may result in significant cost savings within the healthcare system. The underlying assumptions of this analysis include the belief that care coordination is essential to improve patient outcomes, streamline transitions, and elevate the use of resources to reduce complications, prevent unnecessary healthcare expenses, and enhance overall cost-effectiveness. Prevention of hospital readmissions, optimized resource utilization, and effective management of chronic diseases are some of the mechanisms that result in cost-effectiveness due to coordinated care. Healthcare providers collaborating and ensuring a smooth transition of care from the hospital to other settings, such as home or rehabilitation facilities, prevent unnecessary hospital readmissions, ultimately contributing to cost-effectiveness for the organization. According to the literature, preventing single readmission of patients with Medicare results in financial gains of $10,000 – $58,000 as per the Hospital Readmission Reduction Program  (HRRP). Moreover, preventing hospital readmission rates helps an organization save $170 million annually (Yakusheva & Hoffman, 2020).  NURS FPX 6612 Assessment 4 Cost Savings Analysis Furthermore, care coordination enhances resource utilization efficiency within the healthcare system. Through the effective sharing of information using HIT, healthcare providers can make informed decisions about allocating resources for medical tests, imaging studies, and specialist consultations. This results in value-based delivery of healthcare services, avoiding unnecessary duplication of tests and amenities, and leads to cost savings for the organization and patients (Williams et al., 2019). Lastly, chronic diseases often require ongoing and coordinated care. 85% of healthcare costs are invested in the management of chronic diseases. Thus, coordinated care is essential to prevent disease exacerbations, complications, and recurrent hospitalizations, which are the primary reasons for these elevated costs (Holman, 2020). This proactive approach improves the health and well-being of individuals with chronic diseases, resulting in patient cost savings. Overall, care coordination plays a vital role in balancing quality care and cost savings within the healthcare system. Care Coordination and Positive Health Outcomes Health consumerism is the active participation of patients in their healthcare journey. Patient engagement is one of the crucial components of care coordination. Care coordination using HIT tools such as Electronic Health Records (EHRs) and patient portals allows patients to access their health information, empowering them to make healthcare decisions and manage their health effectively. The concept of patient-centeredness elaborates on the cause-and-effect relationship between care coordination and health consumerism. Coordinated care between provider and patients through regular communication, ongoing monitoring, and tailoring patient care plans according to their needs and preferences encourages them to be informed consumers, actively participating in discussions about their treatment options, medications, and lifestyle choices with healthcare providers (Albertson et al., 2022). By informing patients about their healthcare journeys and fostering a collaborative relationship between healthcare providers and patients, care coordination supports shared decision-making, promoting improved health consumerism.  Coordinated care through HIT aids preventive care and early intervention, leading to positive health outcomes. With access to personalized health data, individuals are better positioned to adopt preventive measures and make lifestyle changes that positively impact their well-being (Choi & Powers, 2023). Moreover, collaboration among healthcare providers, facilitated by HIT, provides a holistic understanding of patients’ healthcare needs, enabling timely interventions and reducing the chances of complications. Furthermore, HIT-driven care coordination leads to continuity of care, ensuring a smooth healthcare experience for patients across different settings. This continuity of care augments patient experience, resulting in positive health outcomes and promoting a more holistic and coordinated approach to healthcare practices (Cha, 2023). Care Coordination and Enhanced Evidence-based Data Patient-Centered Medical Homes (PCMH) is an emerging healthcare model focusing on holistic, coordinated, patient-centered care. It involves a collaborative approach to improve patient outcomes through enhanced communication, patient engagement, and continuous quality improvement (De Marchis et al., 2019). Care coordination can enhance the collection of evidence-based data and quality of care using the PCMH model in several ways.  Care coordination through PCMH involves the integration of EHRs to optimize healthcare processes and improve quality. This EHR integration improves the data collection by providing a holistic view of the patient’s health. Moreover, a coordinated and evidence-based data collection approach enables healthcare providers to make evidence-based decisions and tailor care plans to individual needs, improving the quality of care (Jubril, 2019).  The PCMH model emphasizes effective communication and collaboration among healthcare providers. This improved communication ensures immediate sharing of relevant patient health information, facilitating the collection of timely and accurate evidence-based data, ultimately encouraging evidence-based decisions, well-coordinated care, and improved healthcare quality.  NURS FPX 6612 Assessment 4 Cost Savings Analysis Practice changes, performance measures, and benchmarking under the umbrella of PCMH aids in assessing and comparing the quality of care provided. This involves systematic data collection to measure performance against established standards. This evidence-based data collected through care coordination helps the organization to identify areas for improvement and healthcare practices with evidence-based standards to enhance the quality of care (Quigley et al., 2021).  Care coordination enhances the collection of evidence-based data for analytics and modeling, supported by the PCMH model, to identify disease patterns, predict health risks among the population, and tailor

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning Name Capella university NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Patient Discharge Care Planning Patient discharge care planning is a crucial aspect of ensuring continuity of care and preventing hospital readmissions. This assessment is based on Marta Rodriguez, a college freshman who was involved in a car accident in Nevada. She was initially treated at a shock trauma center for four weeks, undergoing multiple surgeries and receiving antibiotic treatment for a systemic infection. Marta recently relocated from New Mexico to Nevada for her studies and has student health insurance coverage. One of the primary considerations in Marta’s care planning is her language preference. Spanish is her native language, while English is her second language. As a senior care coordinator overseeing her case, it is essential to evaluate the key issues that the interprofessional team must address to develop an effective discharge plan. A well-coordinated discharge plan will integrate Health Information Technology (HIT) to facilitate care continuity, data reporting mechanisms to enhance clinical efficiency, and patient-reported health information to improve overall health outcomes. This interprofessional approach will be presented in a team meeting to ensure Marta receives comprehensive and patient-centered post-discharge care. Longitudinal Patient Care Plan HIT plays a vital role in ensuring a smooth transition from hospital care to home-based or outpatient care. Digital tools and telehealth services can enhance patient monitoring, support virtual follow-ups, and promote patient engagement in their recovery process (Abraham et al., 2022). For Marta, Electronic Health Records (EHR) with multilingual support will be crucial in maintaining a detailed and accessible medical history, including her surgeries, medication regimens, and infection treatments. By leveraging real-time data sharing, healthcare professionals can collaborate effectively to make informed decisions about her post-discharge care (Khoong et al., 2020). To enhance Marta’s recovery, the interprofessional team will implement remote monitoring and telehealth platforms to track her medication adherence, schedule virtual follow-ups, and monitor vital signs. Predictive analytics tools and Clinical Decision Support Systems (CDSS) will be employed to assess Marta’s risk factors, such as infection recurrence or post-operative complications, ensuring early interventions when necessary (Somsiri et al., 2020). These technologies will minimize the risk of hospital readmission and support a seamless care transition. Implications of HIT in Care Planning The integration of HIT elements into Marta’s care plan will contribute to a patient-centered approach that enhances care coordination and reduces readmission risks. With access to real-time data, the interprofessional team can promptly address emerging health concerns while engaging Marta in her care process (Srinivasan et al., 2020). The use of EHR and CDSS will further improve communication among healthcare providers, fostering collaboration to ensure Marta’s post-discharge care is well-structured. Additionally, HIT tools support a longitudinal approach to patient care, allowing for proactive interventions and personalized care planning. By leveraging patient data effectively, healthcare professionals can enhance Marta’s recovery outcomes and empower her to take an active role in managing her health (Somsiri et al., 2020). HIT ensures that patient information remains accessible and up to date, reducing the likelihood of treatment errors and enhancing care efficiency. Table Format Representation Key Area Implementation in Marta’s Care Expected Outcomes Longitudinal Patient Care Plan Utilizing EHR with multilingual capabilities to document Marta’s medical history and treatment plans (Khoong et al., 2020). Implementing telehealth platforms for virtual follow-ups and remote monitoring (Abraham et al., 2022). Ensures continuity of care, reduces hospital readmission risks, and allows real-time updates for healthcare providers. Implications of HIT in Care Planning Integrating predictive analytics and CDSS to assess risk factors and enhance decision-making (Somsiri et al., 2020). Using real-time data sharing for collaborative care coordination (Srinivasan et al., 2020). Enhances patient-centered care, improves provider collaboration, and supports proactive health management. Patient Data and Reporting Analyzing Marta’s medication adherence and follow-up attendance for personalized interventions (Kumar et al., 2022). Using reported health data to tailor culturally competent care strategies (Real et al., 2020). Improves clinical efficiency, facilitates timely interventions, and enhances patient satisfaction and engagement. References Abraham, J., Meng, A., Tripathy, S., Kitsiou, S., & Kannampallil, T. (2022). Effect of Health Information Technology (HIT)-based discharge transition interventions on patient readmissions and emergency room visits: A systematic review. Journal of the American Medical Informatics Association. https://doi.org/10.1093/jamia/ocac013 Khoong, E. C., Rivadeneira, N. A., Hiatt, R. A., & Sarkar, U. (2020). The use of technology for communicating with clinicians or seeking health information in a multilingual urban cohort: Cross-Sectional survey. Journal of Medical Internet Research, 22(4), e16951. https://doi.org/10.2196/16951 Kumar, S., Qiu, L., Sen, A., & Sinha, A. P. (2022). Putting analytics into action in care coordination research: Emerging issues and potential solutions. Production and Operations Management, 31(6). https://doi.org/10.1111/poms.13771 NURS FPX 6612 Assessment 3 Patient Discharge Care Planning Real, K., Bell, S., Williams, M. V., Latham, B., Talari, P., & Li, J. (2020). Patient perceptions and real-time observations of bedside rounding team communication: The Interprofessional Teamwork Innovation Model (ITIM). The Joint Commission Journal on Quality and Patient Safety, 46(7). https://doi.org/10.1016/j.jcjq.2020.04.005 Somsiri, V., Asdornwised, U., O’Connor, M., Suwanugsorn, S., & Chansatitporn, N. (2020). Effects of a transitional telehealth program on functional status, rehospitalization, and satisfaction with care in Thai patients with heart failure. Home Health Care Management & Practice, 108482232096940. https://doi.org/10.1177/1084822320969400 Srinivasan, M., Jayant, P., Zulman, D., Thadaney, I., Samuel, M., Robert, S., Lance, D. M., Ian, N., Artandi, M., & Sharp, C. (2020). Enhancing patient engagement during virtual care: A conceptual model and rapid implementation at an academic medical center. NEJM Catalyst. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0262 NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

NURS FPX 6612 Assessment 2 Quality Improvement Proposal Name Capella university NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Quality Improvement Proposal The Medicare and Medicaid Services define ACOs as organizations that deliver high-quality care treatments voluntarily to Medicare patients through effective care coordination (Millwee, 2020). The Sacred Heart Hospital (SHH) under Vila Health seeks to acquire the status of an Accountable Care Organization (ACO).  Assuming the duty of a case manager at SHH, a quality improvement proposal will be recommended to better include quality metrics by expanding the hospital’s HIT with a broad focus on Electronic Health Records (EHRs). Ways to Expand Hospital’s HIT to Include Quality Metrics The EHR system of SHH is outdated and requires appropriate updates to provide a better range of quality metrics on mammograms and colonoscopies. There are several ways by which the EHR system of SHH can be improved by adding extra features such as social work tabs, which will integrate patient health data and keep track of visits with patients. Additionally, the quality metrics relevant to patient care goals will be integrated within EHR (Aerts et al., 2021). These quality metrics will be rates of preventive screenings such as mammograms and colonoscopies, medication errors, patient satisfaction, and quality of care. The SHH will collaborate with public health departments and other clinics to gather data on patients not receiving recommended diagnostic tests, including mammograms and colonoscopies (Dawson et al., 2021).  By utilizing population health data, it will be easier for SHH to identify trends and barriers to care that people encounter during routine diagnostic tests. This data will be analyzed to pinpoint specific patient populations, such as women seeing gynecologists needing targeted interventions (Eckelman et al., 2020). These problems can be solved by implementing care coordination strategies such as leveraging the EHR to identify at-risk patients, practicing reminders and alerts for providers to engage with at-risk patients, and promoting care coordination to achieve higher rates of patients undergoing preventive screenings. This approach will also help track the health information from the community to make necessary improvements based on the gathered data (Watterson et al., 2020). NURS FPX 6612 Assessment 2 Quality Improvement Proposal Several issues can arise during expanding HIT within the organization: The organization requires adequate finances to implement practical ways to enhance EHR features and improve interoperability, including quality metrics. Due to a limited budget, the organization must meet financial requirements such as vendor selection and upgrading EHR systems (Gill et al., 2020). The healthcare organization is vulnerable to inconsistent standardized data, which hinders evaluating the accuracy of gathered data on quality metrics. The organization is also prone to face resistance to changes that are thought to be implemented within EHR and practice clinically. This resistance to change from staff can impact the effectiveness of including quality metrics without making them adequately used (Cho et al., 2021). These issues can be rationally solved by following strategies: Collaborating with other healthcare organizations for funds can improve SHH’s financial capacity. Introduce the standardized data protocols to maximize accuracy in evaluating aggregated data on quality metrics. Educate the healthcare staff on the benefits of using newly upgraded EHR in patient care quality and how it can facilitate timely care treatments (Cho et al., 2021). NURS FPX 6612 Assessment 2 Quality Improvement Proposal Expanding the HIT in the context of upgrading EHRs at SHH integrates the vital roles of informatics in nursing care in the form of nurse informaticists. The nurse informaticist specializes in care coordination through the effective use of HIT, facilitates care planning, and streamlines communication among healthcare staff. Moreover, the nurse informaticist conducts training and educational programs on promoting care coordination by using informatics tools (Gill et al., 2020). The training sessions are tailored to address specific workflows and use cases relevant to nursing care coordination. Similarly, informatics initiatives such as upgraded EHR use in hospitals foster a culture of continuous improvement as the nurses continue to solicit EHR feedback and apply it in initiatives (Eckelman et al., 2020). Using HIT and informatics tools within healthcare systems, including SHH, quality metrics can be better incorporated and utilized to improve patient care. Information Gathering in Healthcare Healthcare systems use patient health information to assess quality metrics and trends in delivering high-quality care and analyze the lagging areas. The primary focus of information gathering in healthcare settings like SHH is to obtain comprehensive data about patients, processes, outcomes, and organizational performance. This information is the foundation for evidence-based decision-making and the development of managerial practices to enhance patient care and operational efficiency (Hathaliya & Tanwar, 2020).  EHRs can be practical tools to gather information about patients’ clinical health data and evaluate treatment performed and achieved outcomes. For example, the information displayed on EHR, including patient demographics, medical history, lab results, medication lists, and treatment plans, can be. Use by clinicians to make well-informed and mindful decisions about patient care (Eckelman et al., 2020).  The organization can also gather data on quality metrics and performance indicators to assess the effectiveness of healthcare facilities. For example, medication errors display the need to include interventions that promote safe medication administration (Lv & Qiao, 2020). Information gathering in the organization also encompasses operational data such as staffing levels and resource utilization. These data help healthcare organizations identify opportunities to improve the quality of care and overall organizational performance (Lv & Qiao, 2020). NURS FPX 6612 Assessment 2 Quality Improvement Proposal   At SHH, healthcare organizations can gather information on these aspects and inquire about patient health data through EHR and personal interviews. One such example from SHH includes communicating with a patient named Caroline McGlade, combatting breast cancer, and describing her lack of knowledge in conducting mammograms and preventive care. The information provided shows a lagging factor behind preventive care at SHH due to financial constraints and need for more education about preventative care (Ye, 2021). Using this information, tailored strategies can be developed and implemented to promote preventive care, essential for SHH to

NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures Name Capella university NURS-FPX 6612 Health Care Models Used in Care Coordination Prof. Name Date Triple Aim Outcome Measures Introduction Hello everyone, my name is ——. As a case manager, I aim to present how the Triple Aim—improving population health, reducing costs, and enhancing the quality of care—can be effectively implemented at Sacred Heart Hospital (SHH). This initiative requires collaboration between hospital leaders and healthcare workers. Additionally, the presentation will explore governmental regulatory programs and outcome measures that contribute to a coordinated care approach, ensuring SHH successfully achieves the Triple Aim. Purpose The primary goal of this presentation is to educate hospital leadership and clinical teams about optimizing the coordinated care process to achieve the Triple Aim in Barnes County Community, where SHH is located. This will be accomplished through patient self-management models, care coordination initiatives, governmental regulations, and measurable outcome strategies. The success of care coordination in achieving the Triple Aim relies on interdisciplinary collaboration among healthcare professionals. Triple Aim and Its Contribution to Healthcare Organizations Experience of Care/Patient Satisfaction Enhancing patient experience at SHH requires a comprehensive approach that prioritizes patient-centered care and effective communication between healthcare providers and patients (Kwame & Petrucka, 2021). Additionally, identifying population needs, such as increasing health literacy, expanding insurance coverage, reducing wait times, and ensuring consistent follow-up care, will enhance patient satisfaction and foster trust between patients and providers. Improving Population or Community Health SHH can improve population health in Barnes County by implementing preventive care programs and health education initiatives. These efforts will help integrate preventive measures into patients’ lifestyles, ultimately enhancing overall health (Yamada & Arai, 2020). Additionally, addressing social determinants such as transportation challenges and low health literacy will increase access to care. Collaborations with other healthcare entities will further enhance resource-sharing and improve health outcomes. Decreasing Per Capita Costs Reducing per capita healthcare costs at SHH requires a balance between cost-effectiveness and quality care. Implementing cost-efficient care models and leveraging technology can optimize healthcare delivery. Furthermore, partnerships with governmental agencies and healthcare organizations will improve financial sustainability, minimize hospital readmission rates, and enhance the hospital’s ability to provide high-quality care within a financially responsible framework (Fichtenberg et al., 2020). Analyzing the Relationship Between Health Models and the Triple Aim Patient Self-Management Model (PSMM) The Patient Self-Management Model (PSMM) focuses on empowering individuals to actively manage their health. By providing patients with knowledge and tools, they can make informed decisions, leading to better health outcomes (Fu et al., 2020). This approach has shifted from a paternalistic model to a collaborative, patient-centered strategy, encouraging autonomy and accountability in managing chronic conditions. PSMM enhances healthcare quality by: Increasing adherence to treatment plans, leading to better outcomes (Lonc et al., 2020). Encouraging preventive care and early intervention, reducing complications. Improving patient satisfaction by fostering collaboration between providers and patients (Du et al., 2019). Care Coordination Model (CCM) The Care Coordination Model (CCM) ensures that healthcare services are seamlessly integrated across various providers and settings. This model emphasizes the importance of communication and collaboration in delivering comprehensive, patient-centered care (Karam et al., 2021). Over time, technological advancements have enhanced interdisciplinary coordination, leading to improved healthcare efficiency. CCM improves healthcare quality by: Reducing fragmented care through streamlined communication among providers (Bloem et al., 2020). Enhancing patient safety by minimizing medical errors (Carayon et al., 2020). Facilitating continuity of care, particularly for chronic disease management (Facchinetti et al., 2020). Both models contribute to the Triple Aim by enhancing patient outcomes, improving care quality, and reducing costs. Structure of Selected Health Care Models Healthcare Model Structure and Components Impact on Triple Aim Patient Self-Management Model (PSMM) Focuses on patient-centered care, self-monitoring, digital health tools, and education Enhances patient autonomy, reduces costs, and improves health outcomes (Solomon & Rudin, 2020). Care Coordination Model (CCM) Integrates care across settings, utilizes electronic health records (EHRs), and enhances interdisciplinary collaboration Reduces hospital readmissions, improves efficiency, and ensures continuous patient care (Awad et al., 2021). Evidence-Based Data in Coordinated Care Enhancing Decision-Making and Communication Evidence-based data plays a crucial role in refining coordinated care by supporting informed decision-making and improving communication among healthcare teams. By analyzing research findings and clinical guidelines, nurses and providers can implement best practices to enhance patient outcomes (Belita et al., 2020). Additionally, streamlined communication through interprofessional collaboration facilitates the development of tailored treatment plans (Hoffmann et al., 2023). Governmental Regulatory Initiatives and Outcome Measures Several regulatory initiatives support the achievement of the Triple Aim: Initiative Description Outcome Measures Health Information Exchange (HIE) Facilitates electronic sharing of patient data across providers Reduces duplicate tests, improves medication reconciliation, and enhances care continuity (Zhuang et al., 2020). Medicare Shared Savings Program (MSSP) Encourages accountable care organizations (ACOs) to coordinate care and lower costs Increases cost savings and enhances patient satisfaction (McWilliams et al., 2020). Meaningful Use Program Incentivizes the adoption of EHRs for better data exchange and care coordination Improves interoperability, enhances patient engagement, and reduces medical errors (Mohammadzadeh et al., 2021). By adopting these regulatory measures, SHH can enhance coordinated care and optimize patient outcomes. Process Improvement Recommendations for Stakeholders Stakeholders Challenges and Concerns Recommended Solutions Healthcare Providers Concerns over initial investment and workflow disruptions Implement pilot programs for gradual adaptation and minimize disruptions. Hospital Administration Concerns regarding workforce adaptability to automation Conduct comprehensive training programs for a smooth transition. Interdisciplinary Teams Need for enhanced communication Develop structured communication protocols for cross-departmental collaboration (Karam et al., 2021). Conclusion To achieve the Triple Aim, SHH must prioritize care coordination through the integration of healthcare models such as PSMM and CCM. These models enhance patient outcomes, reduce costs, and improve overall community health. Through collaboration with healthcare leaders, administrators, and external partners, SHH can successfully implement these strategies to deliver high-quality, cost-effective care to Barnes County Community. I encourage stakeholders to consider these recommendations to ensure sustainable improvements in healthcare delivery. Thank you. NURS FPX 6612 Assessment 1 Triple Aim Outcome Measures

NURS FPX 6610 Assessment 4 Case Presentation Name Capella university NURS-FPX 6610 Introduction to Care Coordination Prof. Name Date Importance of Case Studies in Healthcare Case studies are an essential component of the healthcare industry, offering a comprehensive summary of a patient’s medical history, diagnoses, and available treatment options. These studies serve as valuable resources for tracking patient progress and revisiting cases when necessary to enhance decision-making. Furthermore, case studies facilitate professional learning by incorporating real-world scenarios, which improve healthcare practitioners’ ability to address complex patient needs effectively (Hinchliffe et al., 2020). A key area of focus in healthcare case studies is transitional patient care, which emphasizes the role of multidisciplinary teams in achieving optimal patient outcomes. For instance, understanding the intricate needs of patients transitioning between care facilities significantly improves the quality of care provided. Table 1: Case Studies in Healthcare Aspect Details Example Case Study Definition Provides a concise medical history, diagnoses, and treatments. Real-world scenarios enhance understanding. Importance in Healthcare Aids in patient tracking and decision-making. Revisiting cases improves treatment outcomes. Focus of Discussion Transitional care with multidisciplinary team collaboration. Ensures seamless patient transitions. Transitional Care Plan and Goals of Continuing Care Transitional care refers to the coordinated management of patients as they move between different healthcare settings, ensuring continuity of care and mitigating potential risks during transfers (Daliri et al., 2019). The primary goal of transitional care is to facilitate a smooth and stress-free process while acknowledging patients’ individual needs, cultural preferences, and medical requirements. For example, Mrs. Snyder, a 56-year-old patient diagnosed with ovarian cancer and diabetes, requires a personalized transitional care plan that aligns with her Jewish beliefs. Ensuring that she has access to kosher meals while addressing her complex medical conditions exemplifies the importance of compassionate and culturally competent care. Table 2: Transitional Care and Its Goals Aspect Details Example Definition of Transitional Care Coordination during transitions between healthcare settings. Focus on patient well-being and safety. Goals Ensures stress-free transitions while respecting patient needs. Cultural respect and tailored care plans. Case Example Mrs. Snyder’s transfer from one facility to another. Inclusion of kosher meals in her care. Stakeholder Roles in Patient Health and Safety Stakeholders play a vital role in ensuring the quality of patient care and overall well-being. In cases like Mrs. Snyder’s, healthcare providers, cultural liaisons, and family members must collaborate to minimize stress and honor cultural values. For instance, ensuring that Mrs. Snyder receives kosher food and is treated with dignity throughout her transfer reflects a strong commitment to patient-centered care (Lianov et al., 2020). The active involvement of stakeholders enhances both patient satisfaction and the quality of healthcare delivery, ultimately improving patient outcomes. Table 3: Stakeholder Roles in Patient Care Aspect Details Example Role of Stakeholders Ensure quality care and cultural sensitivity. Minimize stress during transitions. Specific Actions Collaboration between healthcare providers and family. Providing kosher food for Mrs. Snyder. Impact on Outcomes Enhances patient satisfaction and care quality. Improved cultural and medical care. 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 Asmirajanti, M., Hamid, A. Y. S., & Hariyati, Rr. T. S. (2019). Nursing care activities based on documentation. BMC Nursing, 18(1). https://doi.org/10.1186/s12912-019-0352-0 Daliri, S., Hugtenburg, J. G., ter Riet, G., et al. (2019). The effect of a pharmacy-led transitional care program on medication-related problems post-discharge: A before-after prospective study. PLOS One, 14(3), 0213593. https://doi.org/10.1371/journal.pone.0213593 NURS FPX 6610 Assessment 4 Case Presentation Hinchliffe, R. J., Forsythe, R. O., Apelqvist, J., et al. (2020). Guidelines on diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update). Diabetes/Metabolism Research and Reviews, 36(1). https://doi.org/10.1002/dmrr.3276 Lianov, L. S., Barron, G. C., Fredrickson, B. L., et al. (2020). Positive psychology in health care: Defining key stakeholders and their roles. Translational Behavioral Medicine, 10(3), 637–647. https://doi.org/10.1093/tbm/ibz150 NURS FPX 6610 Assessment 4 Case Presentation

NURS FPX 6610 Assessment 3 Transitional Care Plan Name Capella university NURS-FPX 6610 Introduction to Care Coordination Prof. Name Date Transitional Care Plan Transitional care is an essential aspect of ensuring patient safety and quality healthcare. Its primary objective is to facilitate a seamless transition for patients between different phases of treatment, minimizing complications and improving overall health outcomes. This approach is particularly significant for individuals with chronic conditions who require continuous monitoring to prevent adverse effects. This document presents a transitional care plan for Mrs. Snyder, a 56-year-old patient with diabetes who has been admitted to Villa Hospital due to an infected toe. The discussion outlines the key elements of her care, identifies communication barriers, and proposes strategies to enhance the effectiveness of transitional care (Korytkowski et al., 2022). Key Elements and Required Information for Quality Treatment Effective transitional care involves strict adherence to guidelines that ensure optimal patient outcomes. The accurate diagnosis of the patient’s condition is crucial to prevent complications and provide appropriate treatment (Watts et al., 2020). For Mrs. Snyder, maintaining comprehensive medical records, conducting medication reconciliation, providing emergency care details, and considering patient feedback are essential components of quality care. Her medical history offers insights into potential co-existing conditions, such as hypertension or depression, which can influence her treatment plan (Chen et al., 2018). Medication reconciliation is a key factor in ensuring that the prescribed medications align with her treatment goals, reducing the risk of adverse drug interactions (Fernandes et al., 2020). Additionally, emergency directives, including advance care planning, address her healthcare preferences and cultural considerations, fostering a patient-centered approach (Dowling et al., 2020). The availability of community resources, such as mobility assistance, social support, and outpatient care services, further contributes to her recovery and overall well-being (Yue et al., 2019). Insight into Patient Needs and Communication Challenges A well-structured transitional care plan must consider the patient’s needs, including relevant medical test results, prescribed medications, and details of prior hospitalizations. Addressing communication barriers is equally important, as miscommunication can lead to treatment delays, medication errors, and increased healthcare costs (Raeisi et al., 2019). Ensuring that healthcare professionals are trained in effective collaboration and electronic health record (EHR) utilization can help mitigate these risks (Tsai et al., 2020). Strategies for Enhancing Transitional Care A collaborative approach is essential in ensuring a smooth transition from hospital care to home or outpatient services. Proper planning and coordination allow for seamless information exchange, including medication reconciliation lists and discharge instructions, which are crucial for effective patient management (Glans et al., 2020). Follow-up sessions enable healthcare providers to evaluate the success of the care plan, identify gaps, and make necessary improvements. Additionally, educating Mrs. Snyder on self-care strategies, such as maintaining a healthy diet and engaging in regular physical activity, can significantly enhance her long-term well-being (Spencer & Singh Punia, 2020). Summary Table of Transitional Care Plan Heading Details References Key Elements Comprehensive medical records, medication reconciliation, patient feedback, and emergency directives are crucial. Chen et al. (2018), Fernandes et al. (2020), Dowling et al. (2020) Communication Effective communication with healthcare teams minimizes treatment errors, delays, and patient dissatisfaction. Garcia-Jorda et al. (2022), Yazdinejad et al. (2020) Challenges Incomplete records, inefficiencies in EHR systems, and inadequate staff training hinder care continuity. Cullati et al. (2019), Tsai et al. (2020) Conclusion Transitional care plays a critical role in ensuring that patients like Mrs. Snyder receive consistent and high-quality treatment. By addressing communication barriers, fostering teamwork among healthcare providers, and prioritizing patient education, healthcare systems can significantly reduce complications and improve patient satisfaction. Implementing these strategies enhances individual health outcomes while also contributing to the overall efficiency and effectiveness of healthcare delivery. References Chen, Y., Ding, S., Xu, Z., Zheng, H., & Yang, S. (2018). Blockchain-based medical records secure storage and medical service framework. Journal of Medical Systems, 43(1). https://doi.org/10.1007/s10916-018-1121-4 Cullati, S., Bochatay, N., Maître, F., Laroche, T., Muller-Juge, V., Blondon, K. S., Junod Perron, N., Bajwa, N. M., Viet Vu, N., Kim, S., Savoldelli, G. L., Hudelson, P., Chopard, P., & Nendaz, M. R. (2019). When team conflicts threaten the quality of care: A study of health care professionals’ experiences and perceptions. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 3(1), 43–51. https://doi.org/10.1016/j.mayocpiqo.2018.11.003 Dowling, T., Kennedy, S., & Foran, S. (2020). Implementing advance directives—An international literature review of important considerations for nurses. Journal of Nursing Management, 28(6). https://doi.org/10.1111/jonm.13097 Fernandes, B. D., Almeida, P. H. R. F., Foppa, A. A., Sousa, C. T., Ayres, L. R., & Chemello, C. (2020). Pharmacist-led medication reconciliation at patient discharge: A scoping review. Research in Social and Administrative Pharmacy, 16(5), 605–613. https://doi.org/10.1016/j.sapharm.2019.08.001 Garcia-Jorda, D., Fabreau, G. E., Li, Q. K. W., Polachek, A., Milaney, K., McLane, P., & McBrien, K. A. (2022). Being a member of a novel transitional case management team for patients with unstable housing: An ethnographic study. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-07590-6 NURS FPX 6610 Assessment 3 Transitional Care Plan Glans, M., Kragh Ekstam, A., Jakobsson, U., Bondesson, Å., & Midlöv, P. (2020). Risk factors for hospital readmission in older adults within 30 days of discharge – A comparative retrospective study. BMC Geriatrics, 20(1). https://doi.org/10.1186/s12877-020-01867-3 Korytkowski, M. T., Muniyappa, R., Antinori-Lent, K., Donihi, A. C., Drincic, A. T., Hirsch, I. B., Luger, A., McDonnell, M. E., Murad, M. H., Nielsen, C., Pegg, C., Rushakoff, R. J., Santesso, N., & Umpierrez, G. E. (2022). Management of hyperglycemia in hospitalized adult patients in non-critical care settings: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism. https://doi.org/10.1210/clinem/dgac278 Raeisi, A., Rarani, M. A., & Soltani, F. (2019). Challenges of the patient handover process in healthcare services: A systematic review. Journal of Education and Health Promotion, 8(173). https://doi.org/10.4103/jehp.jehp_460_18 Spencer, R. A., & Singh Punia, H. (2020). A scoping review of communication tools applicable to patients and their primary care providers after discharge from the hospital. Patient Education and Counseling. https://doi.org/10.1016/j.pec.2020.12.010 NURS FPX 6610 Assessment 3 Transitional Care Plan Tsai, C. H., Eghdam, A., Davoody, N., Wright, G., Flowerday, S., & Koch, S. (2020). Effects of electronic health record implementation and barriers to adoption and use: A scoping review and qualitative analysis of the content. Life,

NURS FPX 6610 Assessment 2 Patient Care Plan Name Capella university NURS-FPX 6610 Introduction to Care Coordination Prof. Name Date Patient Care Plan for Mrs. Snyder Patient Information Patient Identifier: 6700891 Medical Diagnosis: Poorly controlled anxiety, obesity, hypertension (HTN), diabetes mellitus (DM), and hypercholesterolemia. Nursing Diagnosis 1: Risk of Poor Healthcare Management and Diabetes Complications Assessment Data Mrs. Snyder, a 56-year-old married mother of two, is undergoing treatment for hyperglycemia and uncontrolled diabetes. She has a history of consuming high-sugar snacks. Objectively, she was admitted to the emergency department with blood sugar levels ranging from 230 to 389 mg/dL, along with symptoms such as dyspnea, abdominal discomfort, and urination issues. She also has a diagnosis of hypertension. Goals and Outcomes Mrs. Snyder will maintain blood glucose levels within the range of 90–140 mg/dL over the next two months. She will demonstrate improved dietary habits and a reduction in weight within three months by adhering to a low-sugar, balanced diet. Nursing Interventions and Rationale Educate Mrs. Snyder on self-care management strategies, including dietary control and regular physical activity. Self-care education enhances patient autonomy and promotes effective diabetes management (USC, 2018). Teach blood glucose monitoring and insulin administration techniques to ensure proper diabetes management. Self-monitoring helps regulate insulin dosage and dietary intake (Carolina, 2019). Collaborate with a dietitian to formulate a meal plan that minimizes sugar intake. A structured diet is critical for blood sugar control and preventing diabetes complications (Heart, 2021). Outcome Evaluation and Re-planning Daily glucose level monitoring will be implemented. If the goals are not met, interventions such as increased follow-up visits or alternative medication strategies will be introduced. Nursing Diagnosis 2: Anxiety Related to Caregiving and Health Issues Assessment Data Mrs. Snyder reports experiencing anxiety due to her responsibilities at home and the care of her elderly mother. She feels overwhelmed, resulting in high blood pressure and tachycardia. Objectively, she has an inconsistent intake of anxiolytic medications, with vital signs indicating elevated blood pressure (145/95 mmHg) and tachycardia (105 BPM). Goals and Outcomes Mrs. Snyder’s anxiety levels will decrease by 50% within one month of implementing non-pharmacological interventions. Her blood pressure will stabilize at 130/90 mmHg, and her heart rate will normalize within one month. Nursing Interventions and Rationale Administer prescribed anxiolytics as directed to help manage her anxiety levels. These medications promote mental stability and reduce anxiety symptoms (Ströhle et al., 2018). Refer to cognitive behavioral therapy (CBT) sessions to provide structured coping strategies for stress and anxiety management. CBT is an effective intervention for anxiety-related disorders (Pegg et al., 2022). Connect to a support group for Jewish women facing caregiving stress. Social support plays a crucial role in emotional well-being and stress reduction. Outcome Evaluation and Re-planning Weekly reviews of anxiety levels and blood pressure will be conducted. If progress is inadequate, interventions such as medication adjustments or additional therapy sessions will be considered. Nursing Diagnosis 3: Caregiver Role Strain and Fear of Cancer Treatment Assessment Data Mrs. Snyder expresses concerns about undergoing chemotherapy for ovarian cancer while simultaneously managing her mother’s care. She reports experiencing shortness of breath, and objective data indicates an oxygen saturation level dropping to 91% during ambulation, likely due to her obesity. Goals and Outcomes Mrs. Snyder will arrange long-term care for her mother within two weeks to allow her to focus on her chemotherapy. Her oxygen saturation will improve to 95% with ambulation within one month of initiating treatment. Nursing Interventions and Rationale Refer Mrs. Snyder to a social worker for assistance in securing long-term care for her mother. This support will alleviate caregiver strain and enable her to focus on her health (Hoyt, 2022). Implement non-pharmacological pain management strategies, such as meditation and breathing exercises. These interventions help reduce anxiety and manage pain during cancer treatment (Sheikhalipour et al., 2019). Monitor pain levels and oxygen saturation three times daily to ensure early identification of potential complications. Outcome Evaluation and Re-planning If oxygen saturation and pain management goals are not met, alternative strategies, such as supplemental oxygen or adjustments in pain medication, will be explored. Table Format Nursing Diagnosis Assessment Data Goals and Outcomes Nursing Interventions and Rationale Outcome Evaluation and Re-planning Risk of Poor Healthcare Management and Diabetes Complications Subjective: Mrs. Snyder reports a history of consuming high-sugar snacks. Objective: Blood sugar levels between 230–389 mg/dL, dyspnea, abdominal discomfort, and HTN. 1. Maintain blood glucose within 90–140 mg/dL in two months. 2. Improve dietary habits and reduce weight in three months. 1. Educate on self-care (USC, 2018). 2. Teach blood glucose monitoring and insulin administration (Carolina, 2019). 3. Collaborate with a dietitian for meal planning (Heart, 2021). Monitor glucose levels daily. Adjust follow-up visits and medications if needed. Anxiety Related to Caregiving and Health Issues Subjective: Mrs. Snyder reports anxiety due to caregiving stress. Objective: BP: 145/95 mmHg, HR: 105 BPM, irregular anxiolytic use. 1. Reduce anxiety levels by 50% in one month. 2. Stabilize BP at 130/90 mmHg and normalize heart rate. 1. Administer anxiolytics (Ströhle et al., 2018). 2. Refer to CBT (Pegg et al., 2022). 3. Connect to a support group. Weekly monitoring of anxiety and BP. Adjust medications or therapy as needed. Caregiver Role Strain and Fear of Cancer Treatment Subjective: Mrs. Snyder fears chemotherapy and struggles with caregiving. Objective: Oxygen saturation drops to 91% during ambulation. 1. Secure long-term care for her mother within two weeks. 2. Improve oxygen saturation to 95% within one month. 1. Refer to a social worker for caregiving support (Hoyt, 2022). 2. Implement meditation and breathing exercises (Sheikhalipour et al., 2019). 3. Assess oxygen saturation and pain levels thrice daily. If goals are unmet, consider supplemental oxygen or alternative pain management. References Carolina, C. M. (2019). Unlocking the full potential of self-monitoring of blood glucose. U.S. Pharmacist. https://www.uspharmacist.com/article/unlocking-the-full-potential-of-selfmonitoring-of-blood-glucose Hoyt, J. (2022). Assisted living & senior placement agencies. SeniorLiving.org. https://www.seniorliving.org/placement-agencies/ Pegg, S., Hill, K., Argiros, A., Olatunji, B. O., & Kujawa, A. (2022). Cognitive behavioral therapy for anxiety disorders in youth. Current Psychiatry Reports, 24(12). https://doi.org/10.1007/s11920-022-01384-7 NURS FPX 6610 Assessment 2 Patient Care Plan Sheikhalipour, Z., Ghahramanian, A., Fateh, A., Ghiahi, R., & Onyeka, T. C. (2019). Quality of life in women with cancer. Journal

NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment Name Capella university NURS-FPX 6610 Introduction to Care Coordination Prof. Name Date Nursing Diagnosis and Care Plan for Mrs. Snyder Patient Information Patient Identifier: 6700891 Medical Diagnosis: Poorly controlled anxiety, obesity, hypertension (HTN), diabetes mellitus (DM), and hypercholesterolemia First Nursing Diagnosis: Ineffective Health Management Related to Poor Diabetes Education Assessment Data Mrs. Snyder, a 56-year-old married mother of two, is currently undergoing treatment for hyperglycemia and uncontrolled diabetes. She was admitted to the emergency department with blood sugar levels ranging between 230-389 mg/dL, experiencing symptoms such as dyspnea, lower abdominal discomfort, malaise, and frequent urination. Additionally, she has hypertension and follows an unhealthy dietary pattern, frequently consuming cookies and snacks. Goals and Outcomes Goal 1: Within one month, Mrs. Snyder’s blood sugar and blood pressure levels will stabilize. Goal 2: Over three months, Mrs. Snyder will report improvements in her eating habits and overall health (Ramzan et al., 2022). Nursing Interventions Education on Self-Care Management: Provide guidance on lifestyle modifications, including dietary adjustments, physical activity, and healthy sleep patterns (USC, 2018). Encouragement of Diabetes Self-Monitoring: Teach Mrs. Snyder how to check her blood glucose daily and track her food intake to enhance diabetes management (Carolina, 2019). Insulin Administration Education: Ensure Mrs. Snyder understands the proper techniques for insulin administration to maintain optimal blood glucose control. Rationale Self-care education equips patients with the knowledge necessary to manage diabetes effectively, promoting adherence to medication and lifestyle changes. Improved self-management leads to better collaboration between the patient and the healthcare team (Heart, 2021). Outcome Evaluation and Re-planning Mrs. Snyder’s care team will routinely review her glucose logs to assess the effectiveness of her treatment plan. Based on her progress, adjustments may be made to her dietary plan and insulin use to achieve better glycemic control. Second Nursing Diagnosis: Anxiety Exacerbated by Domestic and Caregiving Responsibilities Assessment Data Mrs. Snyder reports feeling overwhelmed and anxious due to the stress of managing household responsibilities, caring for her ill mother, and conflicts with her son. She has a history of irregular anxiolytic use and presents with high blood pressure and tachycardia. Additionally, she is responsible for handling all financial and family matters, further contributing to her stress and anxiety. Goals and Outcomes Goal 1: Within one month, Mrs. Snyder’s blood pressure will stabilize at 130/90 mmHg, and her heart rate will return to the normal range of 60-100 bpm. Goal 2: Mrs. Snyder’s anxiety will improve through counseling and consistent medication adherence (Pegg et al., 2022). Nursing Interventions Pharmacological Management: Administer anxiolytics as prescribed to alleviate anxiety symptoms. Cognitive Behavioral Therapy (CBT): Arrange weekly counseling sessions to help Mrs. Snyder develop coping mechanisms (Pegg et al., 2022). Support Group Referral: Connect Mrs. Snyder with a support group within her Jewish community to explore mindfulness and spiritual healing therapies. Rationale A combination of pharmacological treatment and non-pharmacological therapies, such as CBT, has been proven effective in reducing anxiety. This holistic approach also helps regulate blood pressure and heart rate, improving overall well-being (Ströhle et al., 2018). Outcome Evaluation and Re-planning Mrs. Snyder’s response to therapy and medication will be monitored weekly. Adjustments to her care plan may be made based on her progress and continued needs for stress management and emotional support. Third Nursing Diagnosis: Psychosocial Distress Related to Ovarian Cancer and Caregiving Burden Assessment Data Mrs. Snyder expresses fear of undergoing chemotherapy and concerns about her ability to care for her elderly mother. She experiences abdominal pain, shortness of breath, and reduced oxygen saturation levels upon exertion. Goals and Outcomes Goal 1: Within 15 days, Mrs. Snyder will secure a care facility for her mother, allowing her to prioritize her own health. Goal 2: Over three months, her physical stamina and oxygen levels will improve. Nursing Interventions Social Work Referral: Assist Mrs. Snyder in finding an appropriate care placement for her mother to alleviate her caregiving burden. Routine Pain Assessment: Conduct pain assessments three times daily to monitor treatment effectiveness. Non-Pharmacological Pain Management: Educate Mrs. Snyder on alternative pain relief strategies such as meditation and yoga (Sheikhalipour et al., 2019). Rationale Providing appropriate care solutions for Mrs. Snyder’s mother will reduce her stress and enable her to focus on her own health. Additionally, non-pharmacological interventions have been shown to effectively manage cancer-related pain, promoting both physical and emotional well-being (Hoyt, 2022). Outcome Evaluation and Re-planning Mrs. Snyder’s pain levels will be closely monitored, and her care plan will be adjusted as needed. Once her mother is placed in a care facility, she will be able to shift her focus toward her cancer treatment and overall well-being. Category First Nursing Diagnosis: Ineffective Health Management Second Nursing Diagnosis: Anxiety Related to Domestic and Caregiving Stress Third Nursing Diagnosis: Psychosocial Distress Due to Cancer and Caregiving Assessment Data Uncontrolled diabetes, hyperglycemia, poor diet, hypertension High anxiety due to caregiving and financial burdens, irregular anxiolytic use, tachycardia Fear of chemotherapy, stress from caregiving, physical symptoms (abdominal pain, shortness of breath) Goals and Outcomes Stabilize blood sugar and BP within one month, improve dietary habits in three months Stabilize BP and heart rate within one month, reduce anxiety with therapy and medication Secure a care facility for mother in 15 days, improve stamina and oxygen levels in three months Nursing Interventions Self-care education, encourage glucose monitoring, insulin administration training Anxiolytic administration, CBT, support group referral Social work referral, routine pain assessment, education on non-pharmacological pain management Rationale Education promotes better diabetes management and adherence to treatment Combining pharmacological and therapy-based interventions is effective in anxiety reduction Addressing caregiving burden allows focus on self-care, non-drug pain management aids in coping Outcome Evaluation Regular review of glucose logs, dietary adjustments as needed Weekly therapy assessment, care plan adjustments based on anxiety response Monitoring pain levels, re-planning based on progress in mother’s care and personal treatment References Carolina, C. M. (2019). Unlocking the full potential of self-monitoring of blood glucose. US Pharmacist. https://www.uspharmacist.com/article/unlocking-the-full-potential-of-selfmonitoring-of-blood-glucose Heart. (2021). Living healthy with diabetes. American Heart Association. https://www.heart.org/en/health-topics/diabetes/prevention–treatment-of-diabetes/living-healthy-with-diabetes NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment Pegg, S., Hill, K., Argiros, A., Olatunji, B. O., & Kujawa, A. (2022). Cognitive behavioral