NURS FPX 4050 Assessment 4 Final Care Coordination Plan EN

NURS FPX 4050 Assessment 4 Final Care Coordination Plan EN

Final Care Coordination Plan

The final care coordination plan aims to create a patient-centered health care intervention with a timeline and conduct a literature review for three health-care challenges. Chronic conditions Cancer, Heart disease, and diabetes in adults that can lead to fatality are discussed further. In a care coordination strategy, nurses play a vital role. They collaborate closely with primary care providers and other primary care colleagues in the primary care network (PCN). This enables them to identify and manage a caseload of identified patients, ensuring that they and their caregivers receive adequate support. This also ensures that their evolving requirements are met. They concentrate on making EBP strategies that provide individualized care that reflects local PCN priorities, health disparities, or at-risk patient groups. They can also assist PCNs in providing Enhanced Health in Care Homes services. (Kuo, McAllister, Rossignol, Turchi, & Stille, 2018).

Patient Centered Health Interventions and Timelines

Chronic diseases and multi-morbidity place a financial and organizational strain on the health-care system. Patients with numerous chronic conditions had higher healthcare costs and usage, as well as lower self-reported health, depression, and functional ability. The Chronic Treatment Model includes community resources, health systems, self-management, designing delivery system, supporting decision and clinical information systems. All of these are integrated together to provide high quality disease care. Nursing has a long history of providing patients with holistic care by combining traditional health care with personalized care. This also involves therapeutic care from several other healthcare disciplines. In all terms of care, nurses provide care based on the individuals’ values, goals, preferences and specific care needs in a variety of acute, post-acute, and community-based care settings, RNs led care coordination projects, interdisciplinary corporation teams, and new care delivery models. These models include cognitive and physical health integration, patient centered medical homes (PCMHs), accountable care organization (ACOs) and emerging payer-based care delivery initiatives. Nurses connect and integrate patients with clinicians and services in order to improve their clinical and  functional performance (McBrien et al., 2018).

Care coordination has been narrowly focused on supportive services for people with chronic diseases who participate in what has become known as the social model of home and community-based care strategies (including coordination at subsidized elderly living sites). Simultaneously, in the fee-for-service health-care system and managed-care schemes, a medical model of care coordination has begun to emerge. As these care coordination initiatives progress, it appears that there is a growing perception that a gap exists between supportive and medical services that must be bridged; a hybrid or integrated approach is emerging. The components of care coordination are examined in this research, as well as a sampling of public programs that link the health and supportive services systems (Facchinetti et al., 2020).

Much of the research on medical care coordination models focuses on provider activities to improve Medicare beneficiary services. Disease management services for beneficiaries with a specific illness and primary care case management services for beneficiaries with complicated socioeconomic and medical issues that put them at high risk of illness and adverse outcomes have been created by states. Both illness management and case management, according to a thorough assessment of guidelines in care coordination (Chen et al., 2000), focus on education for members. Case management services assist members in assessing and managing symptoms, self-monitoring their diseases, avoiding things that cause acute episodes, reducing stress, and adhering to prescriptions, diets, and follow-up regimens. Similar tactics are employed in therapies. However, it’s unclear how many community-based, single-entry systems are establishing connections to primary care practitioners and other health services, the literature analysis uncovered a number of pilot initiatives with the potential for wider replication. While the emergence of care coordination in health plans is described in this paper, it is mostly focused on state initiatives using welfare services such as Medicaid (Bardhan, Chen, & Karahanna, 2020).

Ethical Decisions in Designing Patient Centered Healthcare Interventions

As nurses are advocates for their patients, they must strike a balance when providing patient care. The four major ethical notions are autonomy, beneficence, justice and non-maleficence. Each patient is free to make decisions based on their own personal values and beliefs. The first specific code of ethics for the nursing profession was written in the 1950’s. This statement, written and published by the American Nurses Association (ANA), serves as a guide for nurses in their daily work and specifies the profession’s essential goals and ideas. Its goal is to provide a short summary of every person entering the nursing profession’s ethical obligations and responsibilities. It creates a non-negotiable ethical standard and represents nursing’s own social responsibility perspective. Over time, the Code of Ethics has been updated. Over time, the Code of Ethics has been updated. The latest version takes into account technology improvements and sociological changes. It also consider  nurse practitioner advancement into modern clinical positions, research, education, health policy administration and healthy work environment (Nurses, 2020).

According to a study published in NCBI, nurses should have clear knowledge of position and value their own integrity and moral character as well as the Code of Ethics that governs their profession. Key ethical standards should be understood by all nurses. While advocating for patient rights to self-identify needs and cultural norms, the nursing profession must stay devoted to patient care. Despite their difficulties, nursing ethics are a true integration of the art of patient care.

Patient care coordination must go above and above because it is morally correct and allows the individual (not only the patient) to be treated as an equal partner in therapy, taking into account their needs, parents, backgrounds, strengths, and weaknesses. This analysis is based on Aristotle’s concept of human flourishing, which states that quality is not an e because it is morally correct and can treat the individual (not just the patient) as an equal partner in treatment, taking into account his or her needs, parents, background, strengths, and weaknesses. This study is based on Aristotle’s philosophy of human flourishing, which asserts that quality is a routine, not an expression, and that healthcare providers must improve their emotional (Ferrer, 2018).

Policy Implications for The Coordination and Continuum of Care

The continuum of care in health care refers to how doctors and nurses follow a patient from preventive care to medical emergencies, rehabilitation, and maintenance. Acute care hospital facilities are provided depending upon patient. Vila Health Hospital can strengthen cardiac healthcare systems by implementing patient-centered strategies. Patients confined to the cardiac care unit (CCU) face a variety of issues, despite the challenging symptoms, foreign surroundings, isolation of family and loved ones, and intensive treatment. Toxic stimuli, time pressure, a staffing shortage, and difficult patient outcome circumstances all have an impact on nursing performance and can lower the standard of care provided by nurses on those units (Nekhlyudov et al., 2019).

The authors conducted phone interviews with staff from programmes in Colorado, Georgia, Maine, Massachusetts, New Hampshire, Vermont, and Wisconsin to identify and examine new and emerging care coordination programmes in the states, as well as to learn how existing state home care programmes are addressing health issues. The programmes featured here represent a variety of care coordination methods and contexts. Traditional, socially oriented home and community-based assistance programmes served as the foundation for Colorado and Massachusetts’ care coordination programmes.(McGilton et al., 2018).

The models in Colorado and Massachusetts are likely the most traditional, with little or new linkages to health care.  Maine uses claims data to identify high-risk beneficiaries, after a public housing authority developed a certified home health provider to serve elders living in rental assistance. Physicians receive data on the target demographic from a health educator who has access to medical and pharmaceutical consultants. Georgia connects medical and supportive services by combining primary care and home and community-based services into a single entity. 

Care Coordinator Priorities to Discuss the Plan

 

The National Quality Approach encourages all participants to improve treatment contact and collaboration across the medical system by focusing on three long-term goals. Enhance provider collaboration to improve the standard of care transitioning. Increasing the well-being of people with long-term illness and disability by sticking to a new treatment plan by integrating employee ownership and integrating populations and medical institutions, we can improve the level of care and diminish health inequities. Furthermore, professional nursing staff engages with patients’ caregivers in an open and humane manner. When a member of the nursing staff does not understand a directive, she should disclose her inexperience rather than give an incorrect answer. As a result, patients will have a lot more faith in the nursing team when it comes to healthcare treatment (Blaum et al., 2018).

Learning Session Content Comparison with Best Practices

Healthy People 2030 was published in 2020, providing community health professionals with a significant resource for professional development. The document aids Vila Health Hospital’s specialist and paramedical personnel in enhancing their healthcare outcomes in order to better serve chronic illness patients. Healthy People 2030 includes innovative efforts and approaches to disorder and other difficulties. It implies that enrolling healthy people in a training session will be a great step toward improving cardiac problems treatment because it will surely provide a foundation for nursing personnel to use as milestones. Healthy People 2030, according to Walton’s research, places a greater emphasis on quality of life and environmental health outcomes. This suggests that nurses and other medical staff have ability to apply a proper care coordination plan for the chronic disease patients. This will not solely benefit patients but also nurses in order to provide them suitable time to do their job and home duties simultaneously (Malik, 2018).



















References

Bardhan, I., Chen, H., & Karahanna, E. (2020). Connecting systems, data, and people: A multidisciplinary research roadmap for chronic disease management. MIS Quarterly, 44(1), 185-200. 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan EN

Blaum, C. S., Rosen, J., Naik, A. D., Smith, C. D., Dindo, L., Vo, L., . . . Ferris, R. (2018). Feasibility of implementing patient priorities care for older adults with multiple chronic conditions. Journal of the American Geriatrics Society, 66(10), 2009-2016. 

Facchinetti, G., D’Angelo, D., Piredda, M., Petitti, T., Matarese, M., Oliveti, A., & De Marinis, M. G. (2020). Continuity of care interventions for preventing hospital readmission of older people with chronic diseases: A meta-analysis. International Journal of Nursing Studies, 101, 103396. 

Ferrer, R. L. (2018). Social determinants of health Chronic Illness Care (pp. 435-449): Springer.

Kuo, D. Z., McAllister, J. W., Rossignol, L., Turchi, R. M., & Stille, C. J. (2018). Care coordination for children with medical complexity: whose care is it, anyway? Pediatrics, 141(Supplement_3), S224-S232. 

Malik, S. (2018). The use of community health workers in chronic disease management. 

McBrien, K. A., Ivers, N., Barnieh, L., Bailey, J. J., Lorenzetti, D. L., Nicholas, D., & Edwards, A. (2018). Patient navigators for people with chronic disease: a systematic review. PLOS One, 13(2), e0191980. 

McGilton, K. S., Vellani, S., Yeung, L., Chishtie, J., Commisso, E., Ploeg, J., & Morgan, D. (2018). Identifying and understanding the health and social care needs of older adults with multiple chronic conditions and their caregivers: a scoping review. BMC Geriatrics, 18(1), 1-33. 

Nekhlyudov, L., Mollica, M. A., Jacobsen, P. B., Mayer, D. K., Shulman, L. N., & Geiger, A. M. (2019). Developing a quality of cancer survivorship care framework: implications for clinical care, research, and policy. JNCI: Journal of the National Cancer Institute, 111(11), 1120-1130. 

NURS FPX 4050 Assessment 4 Final Care Coordination Plan EN

Nurses, N. A. O. S. (2020). Framework for 21st century school nursing practice™: clarifications and updated definitions. NASN School Nurse, 35(4), 225-233. 

 

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