Client Name
Capella University
NURS-FPX6610
Instructor’s Name
August 2024
Comprehensive Needs Assessment
Comprehensive needs assessment refers to assessing the condition of the patient’s health condition thoroughly by considering all the factors like social, financial, and psychological (Ravaghi et al., 2023). Identify the information gaps and develop strategies that can be used to acquire complete and transparent information regarding patient history. This information helps the care coordinators in producing positive outcomes regarding patient care and enhances the health quality of the patient. This assessment focuses on identifying current gaps in the care coordination of a simulated patient Mr. Decker who is readmitted to the hospital shortly after discharge. This assessment will also identify the other socio-economic factors that were not considered before to better assess and understand the type of care and treatment needed by Mr. Decker. The additional information will help the case managers and care coordinators better understand Mr. Decker’s condition and provide him best evidence-based treatment.
Current Gap Identification in Mr Decker’s Care
Fred Decker, a 79-year-old man diagnosed with diabetes admitted to Vila Health Systems’ facility with an infected toe. After careful diagnosis and treatment, he was sent back home but a few days later he was readmitted with an even worse toe infection that resulted in sepsis. The readmission of Mr. Decker depends on various factors including;
- The initial process of discharge was not properly reviewed and administered and it does not make sure that Mr. Decker’s wife clearly understood the after-discharge instructions. There was a communication gap and lack of knowledge in Mr. Decker’s family about the importance of instructions that need to be followed timely and strictly to prevent further harm. Lack of proper feedback or follow-up after the discharge is one of the major factors in the readmission of Mr. Decker with severe problems. The inability of the family to take care of the health needs of Mr. Decker is also considered one of the causes of worsened conditions.
Assessment Tool for Assessing Care Gaps
The most suitable tool to assess the gaps in patient care is the Comprehensive Geriatric Assessment (CGA) which is most efficient in identifying the health needs of older patients and the assessment gaps remain unassessed in the analysis of the patient. Using CGA for Mr. Decker helps in identifying the social, medical, psychological, and financial conditions for better treatment and high-quality patient health and safety.
Useful Patient Information for Assessing Care
The most useful patient information for assessing the gaps effectively and efficiently includes the following;
- Detailed analysis of medical history including allergies, chronic diseases, surgeries, vaccinations, medications, or hospital admissions.
- Detailed assessment of present health issues regarding sepsis including pain, blood pressure, weight, and temperature.
- Psychological assessment including anxiety, stress, or disturbed mental condition.
- Financial assessment regarding the insurance or other healthcare facility.
Strategy for Gathering Additional Assessment Data
Ensuring the best care and treatment demands all the additional patient information that can be utilized in treating the patient regarding a particular health issue. To more clearly understand the condition of Mr. Decker additional data is needed that can be obtained through different data-gathering strategies including an interview with the family of Mr. Decker to identify the type of healthcare provided at home and, the ability of the family to follow the healthcare instructions of care coordinator effectively. Involvement of interdisciplinary teams in understanding the health of Mr. Decker from different aspects for better improvement health plan.
The assessment regarding different health perspectives from interdisciplinary teams will help the care coordinators understand the complete medical background of Mr. Decker. Assessing the environment at Mr. Decker’s home will also play a crucial role in understanding the care condition provided to the patient and identifying the other health calamities that can be possible in the home. The appropriate health assessment tools can be beneficial in gathering additional information regarding the health of Mr. Decker and the assessment of resources of community health facilities. More importantly, feedback and follow-ups are mandatory to analyze the progress of health conditions.
All the above-mentioned information-gathering strategies can help in identifying the root cause and underlying issues of the escalating health condition of Mr. Decker and once the issue is identified it becomes easy and efficient for the case managers and care coordinators to effectively design the improvement plan and ensure the proficient implementation of the health improvement strategies regarding the health of patient for better patient outcomes.
Affect of Societal, Economic, and Interprofessional Factors on Patient Outcomes
All the factors including societal, economic, and interprofessional play a significant role in affecting patient outcomes in the context of certain health conditions (McMaughan et al., 2020). The patient’s condition can be imporved more by other factors that are surrounding him all the time than the precautionary health measures. These health measures can be designed according to patients’ condition but after analyzing the above-mentioned factors. The influence of these factors on the patient outcomes is given below;
Societal Factors
Societal factors including the patient’s ability to understand his health condition and the instructions and act upon the precautionary measures to ensure high-quality health outcomes play a major role in generating positive patient outcomes (McMaughan et al., 2020). The health beliefs of the patient also affect the type of treatment he is willing to receive and his perceptions regarding health issues and medications. Family support helps in the fast recovery of the patient from any bad health condition.
Economic Factors
Economic factors also have a major impact on patient outcomes as these factors evaluate the financial situation of patients and their ability to get access to healthcare facilities including medicines, checkups, and health tests for various assessments (McMaughan et al., 2020). The employment and health insurance situation of the patient are the major factors that influence the patient outcomes.
Interprofessional Factors
Effective interdisciplinary team collaboration regarding patient conditions can positively impact patient outcomes (Taberna, 2020). Involving the family’s opinion regarding the patient’s condition for a better decision-making process, the competency and ability of the care coordinators and health providers, and the management of stress and burnout also have a major influence on patient outcomes.
Relating Patient And Care Coordination Outcomes To Professional Standards
Professional standards are necessary to ensure the high-quality health and care of the patients along with improved positive patient outcomes. These standards provide basic guidance regarding the designing and implementation of health plans for patients. Hence patient and care coordination results are widely dependent on professional standards. These standards make sure that the quality of health and the efficiency of the team providing healthcare to the patients should be enhanced and well managed. The American Nurses Association (ANA) highlights the importance of patient safety and care which motivates the care coordinators to follow the ANA standard and provide improved care to the patients (Karam et al., 2021).
Healthcare practices based on evidence are highly considerate in improving patient outcomes as they increase the efficiency of care coordinators in treating patients efficiently. Interprofessional collaboration has a significant impact on patient outcomes as team collaboration produces enhanced strategies to improve the health quality of the patients. Ethical practices in a workplace environment are of major importance in generating positive patient outcomes as they make sure that the patients are treated with respect and dignity (Haddad & Geiger, 2023). The continuous provision of quality care to a diverse population is the most crucial aspect of professional standards and positive patient outcomes.
Evidence-Based Practices For Successful Implementation Of Care Coordination
Practices based on evidence are of huge importance in providing high-quality health care to patients as these practices are based on scientifically proven data and can help healthcare professionals in dealing with situations regarding healthcare (Engle et al., 2021). Care coordination can also be successfully implemented using evidence-based interdisciplinary practices. Involving patients and their families in the decision-making process regarding the care provided to the patients has a proven successful evidence-based significance as it shows improved patient outcomes.
Collaboration of health professionals and interdisciplinary teams always generates outcomes that are most beneficial to the patients and the organization because of the shared knowledge and experience of the professionals. The collaboration of all the teams and disciplines for the common goal of providing high-quality and proficient care to the patients results in effective outcomes. Moreover, the advancements in technology and the emerging importance of healthcare information technology have a great impact on the successful implementation of care coordination the use of electronic health records facilitates the staff members and the patients for easy access and updated data (Vos et al., 2020).
These electronic records help in the reduction of work stress and staff burnout and provide the advantage of responding early to deteriorating patient conditions thus preventing disparities related to health and care. Efficient and transparent communication also plays a key role in creating positive patient outcomes due to a clear understanding of the instructions and precautions needed to improve patient health.
Benefits of a Multidisciplinary Approach to Patient Care
Collaboration of multidisciplinary teams enhances the quality of knowledge and information shared and gathered regarding specific patient conditions or any other health issue (Taberna, 2020). The multidisciplinary approach helps in gathering information regarding health from all aspects including social, economic, psychological, and cultural for a better understanding of the medical history of the patient and to generate enhanced and improved patient health results. Team collaboration can also reduce single staff member efforts and increase the work efficiency of the workers by sharing and collaborating the effective work techniques and their successful implementation.
The collaborative communication between the team members of disciplinary teams results in improved and effective communication with the patients regarding their health conditions, instruction about their treatment, and further health outcomes (Bendowska & Baum, 2023). Informed patients are more vulnerable to positive outcomes than the ones who have no knowledge or insufficient knowledge regarding their health condition due to which they are unable to follow the instructions and understand the need for treatment.
The interdisciplinary team approach also helps in the efficient utilization of resources including human resources and organizational resources by analyzing the needs of all disciplines and allocating the resources according to the best accommodate (Warren & Warren, 2023). A major factor of interdisciplinary team collaboration is the enhancement and improvement in the professional development of the staff which ultimately leads to better patient outcomes and the overall progress of the organization.
NURS FPX 6610 Assessment 1 Conclusion
Understanding the patient’s needs for the detailed analysis of the medical history of the patient and better patient outcomes is necessary for any healthcare facility to reduce the rate of readmissions (Rammohan et al., 2023). Evaluating the societal, economic, and psychological factors of the patient’s health thoroughly leads to better care coordination of the patient and improved quality of treatment offered by the case managers. The gaps in gathering needed information regarding the patient’s medical history can lead to severe and poor health conditions of the patients and thus readmitting the patient to the hospital becomes necessary (Kayyali et al., 2020).
To avoid readmissions and any health disparities effective strategies need to be implemented to gather additional information about the patient’s medical history. Professional standards also make sure that quality health and care are provided to the patients by strictly monitoring the implementation of guidelines and strategies proposed by the legal authorities. Moreover, evidence-based practices also have a significant impact on positive patient outcomes due to efficient care coordination and collaborative efforts of interdisciplinary teams.
NURS FPX 6610 Assessment 1 References
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Engle, R. L., Mohr, D. C., Holmes, S. K., Seibert, M. N., Afable, M., Leyson, J., & Meterko, M. (2021). Evidence-based practice and patient-centered care: Doing both well. Health Care Management Review, 46(3), 174–184. https://doi.org/10.1097/HMR.0000000000000254
Haddad, L. M., & Geiger, R. A. (2023). Nursing ethical considerations. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526054/
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Ravaghi, H., Guisset, A., Elfeky, S., Nasir, N., Khani, S., Ahmadnezhad, E., & Abdi, Z. (2023). A scoping review of community health needs and assets assessment: Concepts, rationale, tools and uses. BMC Health Services Research, 23(1), 1–20. https://doi.org/10.1186/s12913-022-08983-3
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