Client Name
Capella University
NURS-FPX6614: Structure and Progress in Care Coordination
Instructor’s Name
September 2024
Defining a Gap in Practice: Executive Summary
The deficiency in practice in a particular area can be improved through various strategic improvements according to the health needs of the specific area or group (Ali et al., 2021). The determination of a gap in practice can help healthcare organizations and healthcare professionals introduce strategies and technologies that can reduce that gap and help the community build a safe environment (Robinson et al., 2020). This assessment will define the clinical practices that are best suited for the population to reduce a gap through the application of the PICOT formula. It will focus on the resources for effective implementation of care coordination policies to improve the health outcomes of the people living with a certain health issue.
Clinical Priorities for a Specific Population
Advanced and improved healthcare services are needed to enhance the patient experience and reduce any lack of recognizing and responding to the healthcare problem (Ferreira et al., 2023). Various practices based on evidence serve as a cornerstone in providing the best healthcare facilities and staff assistance to older people suffering from diabetes (Northwood et al., 2022). The clinical priorities include active monitoring of blood glucose levels, and cholesterol, proper medication, and blood pressure, as well as the diabetic diet (Gray & Threlkeld, 2024). These factors act as driving forces in the diagnosis and prevention of diabetic diseases, especially in older people.
Moreover, adequate family support, appropriate analysis of mental health conditions, or any stress factors like anxiety, and depression need to be responded to with great care (Mofatteh, 2020). The gaps in patient information regarding medical history need to be properly identified so that no missing information can affect the treatment process. In case of excessive healthcare readmissions, financial issues of the patient’s strategies that are based on technology or collaboration of global healthcare organizations need to be implemented to ensure that health is accessible to all the population.
Applying a PICOT Question to a Gap in Practice
To identify the practice gap in elderly adults suffering from diabetes the PICOT question will be:
In older people suffering from type 2 diabetes (P), does the application of telehealth services (I), compared to traditional care services (C), decrease the readmission hospital rates (O), within the four months (T)?
This question undermines the need to implement telehealth services to reduce the readmission rates of patients with diabetes disease to reduce the gaps in practice and increase the number of effective and enhanced patient outcomes (Dhediya et al., 2022). PICOT identifies the importance of new advanced technologies to address the healthcare problems of the patients who are most vulnerable to reduce health disparities and increase the best chances at life (Dost et al., 2024).
Potential Services And Resources For Care Coordination
Effective coordination of care is essential for older adults suffering from diabetes due to their high health demands (Bartkeviciute et al., 2022). Proper consultation and healthcare programs can help patients monitor their blood glucose levels effectively and follow physical health activities to improve through other factors than medicines. Education and training regarding self-management should be provided to the patients so that the people who can’t visit hospitals often can manage and maintain their better help through their health services (Otter et al., 2022). This increases awareness among people which helps in reducing risk factors and disease count. The collaboration of interdisciplinary teams helps in decreasing the disease and increasing the success rate of positive patient outcomes. The health services or technologies that are patient-centered are more beneficial in improving the quality of healthcare services.
Care Coordination Intervention To Enhance Evidence-Based Practice
The patient-centered medical home (PCMH) is of great significance in providing enhanced services based on evidence to the patient having diabetes. This model specifically focuses on the health and needs of a single patient by providing the most efficient staff an dthe resources to the patients. The involvement of interdisciplinary teams along with advanced technology can upgrade the process of care coordination based on evidence. Well-regulated feedbacks from the patients after discharge also help in reducing hospital readmissions and emergencies which ultimately leads to enhanced patient outcomes.
Nursing Diagnosis to Support the Strategy for Collaborative Care
The nursing analysis of “Inadequate Health Maintenance” is a major factor in supporting collaborative care strategies. Integrating proper education and straining the patient regarding the monitoring and analysis of the health condition is necessary to prevent harmful events (AbdulRaheem, 2023). Appropriate medications and the cooperation of interdisciplinary teams can also help in reducing health risks and managing the safety of the patient effectively (Bendowska & Baum, 2023).
The change in diet according to a diabetic-rich diet and physical activities also helps in increasing patient awareness regarding health efficiency and self-management (Mphasha et al., 2024). Technology is one of the major components that can increase the effectiveness of care coordination along with the intervention of interprofessional.
Planning of the Intervention and Expected Outcomes
The intervention planning is based on the analysis of the needs of the patients along with their health conditions (Butler & Thayer, 2023). The proper measurement of blood glucose levels, blood pressure, and cholesterol of elderly patients needs to implement effective collaboration with the cooperation of interdisciplinary teams. Appropriate education and self-management training for the patient can help reduce the rate of high-level diabetes and keep it to a normal level (Adu et al., 2019).
The use of electronic health records (EHR) helps in accurate and timely monitoring and data saving of the patient regarding the health condition which ultimately helps the regularly monitoring healthcare providers in understanding the patient’s condition proficiently and suggesting changes needed to implement in the plan (Aguirre et al., 2020). The above-mentioned interventions can not only enhance patient experience but also generate positive health outcomes.
NURS FPX 6614 Assessment 1 Conclusion
Practice gaps lead to healthcare disparities which eventually badly impact the patient, staff members, and the organization as a whole (Kumar et al., 2022). PICOT questions can be used to properly address the lack of healthcare for elderly adults suffering from type 2 diabetes. The care coordination services based on evidence are a key factor in improving patient health experiences and cost reduction of healthcare resources. The ineffective management plans can be improved through the proper planning of intervention strategies and positive expected results.
NURS FPX 6614 Assessment 1 References
Adu, M. D., Malabu, U. H., Aduli, A. E. , & Aduli, B. S. (2019). Enablers and barriers to effective diabetes self-management: A multi-national investigation. PLOS ONE, 14(6), e0217771. https://doi.org/10.1371/journal.pone.0217771
Aguirre, R. R., Suarez, O., Fuentes, M., & Gonzalez, M. A. (2020). Electronic health record implementation: A review of resources and tools. Cureus, 11(9). https://doi.org/10.7759/cureus.5649
Ali, N. Z., Fun, W. H., Ismail, M., Ng, R. J., Jaaffar, F. S., & Low, L. L. (2021). Addressing gaps for health systems strengthening: A public perspective on health systems’ response towards COVID-19. International Journal of Environmental Research and Public Health, 18(17), 9047. https://doi.org/10.3390/ijerph18179047
Butler, T. J., & Thayer, J. M. (2023). Nursing Process. National Library of Medicine. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499937/
Bartkeviciute, B., Riklikiene, O., Kregzdyte, R., & Lesauskaite, V. (2022). Individualized care for older adults with diabetes and its relationship with communication, psychosocial self‐efficacy, resources and support for self‐management and socio‐demographics. Nursing Open, 10(4), 2560–2571. https://doi.org/10.1002/nop2.1515
Bendowska, A., & Baum, E. (2023). The significance of cooperation in interdisciplinary health care teams as perceived by polish medical students. International Journal of Environmental Research and Public Health, 20(2). https://doi.org/10.3390/ijerph20020954
Dhediya, R., Chadha, M., Bhattacharya, A. D., Godbole, S., & Godbole, S. (2022). Role of telemedicine in diabetes management. Journal of Diabetes Science and Technology, 17(3), 193229682210811. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10210114/
Dost, Gastaldi, G., Dos, M., & Schneider, M. P. (2024). Navigating outpatient care of patients with type 2 diabetes after hospital discharge – A qualitative longitudinal study. BMC Health Services Research, 24(1). https://doi.org/10.1186/s12913-024-10959-4
Ferreira, D. C., Vieira, I., Pedro, M. I., Caldas, P., & Varela, M. (2023). Patient satisfaction with healthcare services and the techniques used for its assessment: A systematic literature review and a bibliometric analysis. Healthcare, 11(5), 639. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10001171/
Gray, A., & Threlkeld, R. J. (2024). Nutritional recommendations for individuals with diabetes. MDText.com. https://www.ncbi.nlm.nih.gov/books/NBK279012/
Kumar, P., Sinha, A., Kumar, A., & Alam, M. (2022). Barriers and facilitators of providing standard of care diabetes management at primary care level in geriatric population. Journal of Family Medicine and Primary Care, 11(10), 6451. https://doi.org/10.4103/jfmpc.jfmpc_851_22
Mofatteh, M. (2020). Risk factors associated with stress, anxiety, and depression among university undergraduate students. AIMS Public Health, 8(1), 36–65. https://doi.org/10.3934/publichealth.2021004
Mphasha, M. H., Skaal, L., & Mothibal, T. (2024). Diet and exercise knowledge and practices for diabetes care within families in Senwabarwana. South African Family Practice, 66(1). https://doi.org/10.4102/safp.v66i1.5767
Northwood, M., Shah, A. Q., Abeygunawardena, C., Garnett, A., & Schumacher, C. (2022). Care coordination of older adults with diabetes: A scoping review. Canadian Journal of Diabetes, 47(3). https://doi.org/10.1016/j.jcjd.2022.11.004
Otter, C. E., Keers, J. C., Reker, C., Smit, J., Schoonhoven, L., & Ginkel, J. M. (2022). How nurses support self-management of hospitalized patients through verbal communication: A qualitative study. BMC Nursing, 21(1). https://doi.org/10.1186/s12912-022-01099-3
Robinson, T., Bailey, C., Morris, H., Burns, P., Melder, A., Croft, C., Spyridonidis, D., Bismantara, H., Skouteris, H., & Teede, H. (2020). Bridging the research–practice gap in healthcare: A rapid review of research translation centres in England and Australia. Health Research Policy and Systems, 18(1). https://doi.org/10.1186/s12961-020-00621-w
Raheem, Y. (2023). Unveiling the significance and challenges of integrating prevention levels in healthcare practice. Unveiling the Significance and Challenges of Integrating Prevention Levels in Healthcare Practice, 14(1), 1–6. https://doi.org/10.1177/21501319231186500