NURS FPX 6612 Assessment 3 Patient Discharge Care Planning
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