Client Name
Capella University
NURS-FPX6610: Introduction to Care Coordination
Instructor’s Name
August 2024
Case Presentation
Slide 2: Hello, my name is —. The topic of today’s presentation is identifying the care coordination plan and the transitional care plan of a case study based on Mrs.Snyder a woman aged 57 years old who is suffering from ovarian cancer diagnosed at stage 4. Due to her worsening condition, she was transferred to hospice from the curative care unit. The presentation will elaborate on the goals and the complete scope of the continuing care plan designed to fulfill the healthcare needs of Mrs.Snyder and identify the decision-making of stakeholders in providing efficient health and safety to Mrs.Snyder (Comer et al., 2020). This information will help the stakeholders or the destination care agencies to understand the care needed by Mrs. Snyder and implement the best care strategies for better patient outcomes.
Scope and Goal of Transitional Plan for Continuing Care
Slide 3: A transitional care plan was designed and developed to provide quality effective care and safety to Mrs.Snyder (Earl et al., 2020). Transitional plans help provide the required health needs of the patient during the transition and after the transition from one healthcare facility to another. The Transitional care plan was based on the identification of the patient’s health requirements and managing the health needs to successfully implement the plan for better patient outcomes (Earl et al., 2020). In the case of Mrs. Snyder, she needs extra health assistance to ensure her safe transfer and maintain her high-quality health at the destination care facility.
To ensure the proficiency of care at the destination care facility a continuing care plan is needed. This plan should focus on effectively managing and reducing the pain of Mrs.Snyder due to stage 4 cancer along with efficient monitoring of her diabetes levels and the diet she is taking to control her diabetes. Proper measures should be implemented to ensure that her anxiety does not exceed and skin damage due to obesity should be reduced. This plan can only be successful by the coordination and support of the patient’s family.
Key Elements of Continuing Care Plan
Slide 4: The Care Plan for further life healthcare needs to be well designed so that it can focus and manage all the aspects of patient health to generate better patient outcomes (Bhati, 2023). The key elements of a continuing care plan are as follows;
- Appropriate assessment of the pain using the standardized pain scale and monitoring the changes needed in a management health and pain plan for reducing the risk regarding health disparities (Dydyk & Grandhe, 2023).
- Continuous assessment of diabetes and strategies implementation to control the escalating levels of diabetes before and after meals.
- Providing a proper diet plan to ensure that the diet is according to the diabetes control management plan.
- Physical health activities and the proper skin care practices should be included in the plan.
- Adequate support and coordination of the family in ensuring well being of the patient and high stability.
Stakeholders Role in Continuing Care Plan
Slide 5: The stakeholders involved in the plan of continuing care include the patient, her family members, healthcare professionals, case managers, nutritionists, hospice nursing, and healthcare staff (Lama et al., 2023). They all play a crucial role in delivering high-quality health to the patient by playing their roles significantly and proficiently. The health and care needs and preferences indicated by Mrs.Snyder are the major concerns of the continuing plan of care as she can demonstrate her pain levels, new and old symptoms regarding health issues, and the impacts of the pain management plan.
The healthcare professionals and other interdisciplinary teams play an effective role in highlighting the medical needs of Mrs. Snyder including medications, their dosage, changes in prescriptions, and monitoring schedule of health outcomes for a better understanding of patient health and the care requirements (Bendowska & Baum, 2023). Moreover, the family of Mrs.Snyder has an important role in providing support thus helping her in reducing her stress and anxiety regarding cancer treatment outcomes and other diseases.
Accurate and Complete Information of Mrs. Snyder
Slide 6: Mrs. Snyder is a 57-year-old woman suffering from stage 4 ovarian cancer, high anxiety and obesity, hypertension, hypercholesterolemia, and uncontrolled diabetes. Her cancer was exacerbated and became untreatable due to which she was transferred to hospice (Hugar et al., 2021). She is suffering from severe pain due to chemotherapies and she was afraid of the outcomes of her treatment. She is unaware of her diabetic dietary needs and unable to maintain her blood glucose level which remains between 190 mg/dL after meals and 150 mg/dL before meals. She belongs to an orthodox Jewish family and prefers to follow religion in her healthcare regime including a specific diet such as kosher food and an understanding of her cultural preferences (Peles et al., 2021). All these factors collectively demonstrate the type of care needed by Mrs.Snyder for her hospice healthcare and the collaboration and support of the family for better outcomes.
Stakeholders Decision-Making in the Best Interest of Mrs.Snyder
Slide 7: Decision-making regarding the healthcare needs of Mrs.Snyder needs a collaborative approach involving all the key stakeholders of the case and the interdisciplinary support team to identify and implement her medical preferences, religious beliefs, values, and healthcare needs for delivering high-quality and proficient assistance to Mrs. Snyder (Deckers & Zaalen, 2024). Her consent for providing effective and efficient health care is of major importance while deciding for her better life. Proper pain management strategies and diabetes control plans should be implemented with great care after evaluation by the case managers and healthcare professionals.
Role of Interprofessional Care Team in Delivering High-Quality Patient Outcomes
Slide 8: Considering the situation of Mrs.Snyder is suffering from various health problems including psychological, medical, and social, and for the effective solution to these problems a strong collaborative approach of interprofessional is needed to ensure that high-quality health, care, and safety is provided to Mrs.Snyder (Deckers & Zaalen, 2024). Moreover, the cooperation of interdisciplinary teams on a particular issue always generates results that are based on exposure to different disciplines and experiences this results in the most effective results leading to great advantages both for the patient and the organization. The roles of a few major stakeholders of the interprofessional team are given below;
- The responsibility of the nurses is to regularly monitor the health condition of Mrs.Snyder along with the implementation of changes required in the improvement plan (Flaubert, 2021).
- The role of physicians is to make sure that Mrs.Snyder is getting treatment for her cancer based on evidence-based practices.
- To control the exacerbated levels of diabetes dietitians must provide a diet plan for their diabetic diet.
- The major responsibility of case managers is to ensure the smooth and effective transition of Mrs.Snyder from the curative healthcare unit to hospice healthcare for better patient outcomes.
Informational Needs of Stakeholders
Slide 9: Information regarding the patient’s health condition, medical history, any treatments or surgeries, and diet plans are crucial to analyzing the situation and implementing best evidence-based practices (Nichol et al., 2023). The accurate data about the financial situation of Mrs.Snyder and her societal condition is a very important bot for the successful implementation of the transitional plan of care and the continuing plan of care. Based on accurate information the destination care agencies will be able to provide healthcare to Mrs.Snyder according to her needs, preferences, and specifications. Psychological information is also needed by the stakeholders to effectively communicate with the patient regarding her health needs.
Factors Affecting Patient Outcomes
Slide 10: Patient-improved and enhanced outcomes are one of the major concerns of healthcare professionals, case managers, stakeholders, and the organization (Bhati, 2023). Patient outcomes help effectively the care teams to analyze and understand the change requirements of the patient for the pain management plan, diet plan, diabetes control management plan, and so on. A few factors affecting patient outcomes are given below;
Medical Factor
Access to desired healthcare results in the most effective patient outcomes along with the well-being and satisfaction of the patient (Ferreira et al., 2023). These factors majorly depend on the understanding of the health team about the medical history of Mrs. Snyder and the quality of treatment provided.
Societal Factor
Societal factors are of major importance as they involve a lot of factors that can affect the outcome of Mrs. Snyder including her religious beliefs, social support system, access to basic healthcare needs and services, and proper home environment for mental and physical health.
Financial Factor
Financial factor determines the health care specifications of the patient. In the case of Mrs.Snyder there as such no financial problem involving the treatments or healthcare services for her better health.
Assumptions and Areas of Uncertainty
Assumptions regarding the response of Mrs.Snyder to hospice healthcare need to be evaluated and analyzed based on her changing health condition (National Guideline Centre (UK), 2019). The worsening of cancer conditions and the outcome of different management plans including plans and diabetes plans create uncertainty that needs to be considered for evaluation and improved understanding of the patient requirements regarding health.
Resources Needed to Implement Continuing Care
Slide 11: The continuing care plan focuses entirely on the health outcomes of the patient that are obtained as a result of the efficient patients’ health requirements fulfillment of the staff (Galletta et al., 2022). This quality can be maintained if proper treatment is given to the patient by properly identifying the medical, social, and psychological history of the patient. Useful resources according to the needs of the patient are mandatory for the smooth transition and better outcome of the continuing care plan. A few resources that are needed are mentioned below;
Diabetes and Pain Management Resources
Resources are needed to maintain and monitor effectively the pain levels of Mrs.Snyder due to cancer and the diabetes level from and after meals for better implementation of the medication and caring needs (Davies et al., 2022). Proper pain management standardized tools should be available and diabetes management apparatus should be present in a healthcare setting to reduce the risk of health disparities and ensure the refined planning of emergencies.
Financial Resources
Financial Resources should be complete for the improved and advanced treatment of the patient and the proper management of the finances.
Effective Communication Resources
The role of communication in patient transition is of great importance as effective communication ensures that accurate and timely information is provided to the destination care hospital for a controlled and healthy patient condition.
NURS FPX 6610 Assessment 4 Conclusion
Slide 12: Transitional care plans are an important part of ensuring a smooth and effective transition of patients from one healthcare setting to another. This plan ensures that the health and care needs of the patient should be met effectively and efficiently (Comer et al., 2020). The continuing care plan takes the effectiveness of the transitional plan to the next level by administering the requirement of the patient regarding health according to the information acquired from the transition hospital and the patient for better patient outcomes. The stakeholders and interprofessional teams play crucial roles in ensuring the effective design, development, and implementation of a continuing plan of care. Best evidence-based practices ensure that patient outcomes must be positive and improved continuously. Continuous improvement of patients majorly depends on the healthcare resources available to the healthcare organizations and the patients.
NURS FPX 6610 Assessment 4 References
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
Bhati, D. (2023). Improving patient outcomes through effective hospital administration: A comprehensive review. Cureus, 15(10), 1–12. https://doi.org/10.7759/cureus.47731
Comer, A., Fettig, L., & Torke, A. M. (2020). Identifying goals of care. Medical Clinics of North America, 104(5), 767–775. https://doi.org/10.1016/j.mcna.2020.06.002
Davies, M. J., Aroda, V. R., Collins, B. S., Gabbay, R. A., Green, J., Maruthur, N. M., Rosas, S. E., Prato, S., Mathieu, C., Mingrone, G., Rossing, P., Tankova, T., Tsapas, A., & Buse, J. B. (2022). Management of hyperglycaemia in type 2 diabetes, 2022. Diabetologia, 65(12). https://doi.org/10.1007/s00125-022-05787-2
Deckers, M., & Zaalen, Y. (2024). Insights into shared decision-making in interprofessional teams for a boy with down syndrome with communication and language issues: Simulation-based training for medical and allied health students. Healthcare, 12(6), 681–681. https://doi.org/10.3390/healthcare12060681
Dydyk, A. M., & Grandhe, S. (2023). Pain assessment. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556098/
Earl, T., Katapodis, N., & Schneiderman, S. (2020). Care transitions. Agency for Healthcare Research and Quality (US). https://www.ncbi.nlm.nih.gov/books/NBK555516/
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/
Flaubert, J. L. (2021). The role of nurses in improving health care access and quality. In National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK573910/
Galletta, M., Piazza, M. F., Meloni, S. L., Chessa, E., Piras, I., Arnetz, J. E., & Aloja, E. (2022). Patient involvement in shared decision-making: Do patients rate physicians and nurses differently? International Journal of Environmental Research and Public Health, 19(21). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9656720/
Hugar, L. A., Burchfield, E. M., Winzelberg, G. S., Jacobs, B. L., & Davies, B. J. (2021). Incorporating palliative care principles to improve patient care and quality of life in urologic oncology. Nature Reviews Urology, 18(10), 623–635. https://doi.org/10.1038/s41585-021-00491-z
Lama, S., Nynke, J., Alsaywid, B. S., & Jascha, N. (2023). A qualitative study of stakeholders’ perspectives of implementing interprofessional shared decision-making education in palliative care. ProQuest. https://doi.org/10.7759/cureus.44039
National Guideline Centre. (2019). Evidence review: Barriers to accessing end of life care services: End of life care for adults. National Institute for Health and Care Excellence (UK). https://www.ncbi.nlm.nih.gov/books/NBK558767/
Nichol, J. R., Nelson, G., & Sundjaja, J. H. (2023). Medical History. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534249/
Peles, C., Shloim, N., & Rudolf, M. C. (2021). Over-preoccupation with healthy food is perceived as worship of the body: Food, culture and beliefs in ultra-orthodox jewish families. Appetite, 167, 105621. https://doi.org/10.1016/j.appet.2021.105621