NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Introduction

The Centers for Medicare and Medicaid Services (CMS) analyzes the patient experience using surveys that ask patients about their experiences or perceptions of essential parts of their care, not about their satisfaction with their care. Patient experience surveys inquire about patients’ perceptions of essential areas of health care, such as contact with doctors, comprehension of prescription instructions, and coordination of their healthcare requirements (Centers for Medicare and Medicaid Services [CMS], 2022). The hospital patient experience for Marta Rodriguez, a college student involved in a motor vehicle collision, begins in the field where EMS brought her to the nearest trauma level one ED, where she underwent four weeks of therapy. Now we are at a point of transition out of the hospital to a post-acute care setting.

Each provider assessment, special test ordered, therapy evaluation, psychology progress note, RN intervention, hospital transport to a procedure has vital information to provide longitudinal, patient-centered care planning that moves the patient across the continuum of care. Health Information Technology (HIT) holds patient data of care given, upcoming appointments, or procedures and interacts with other hospital HIT systems. The availability to collect and analyze the patient’s entire electronic health record (EHR) allows for Care Coordination that is safe and effective in the discharge plan. This paper will examine the case study of Marta Rodriguez and the interventions of the interdisciplinary team that consider the key aspects of a safe and successful discharge plan from the hospital.

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Longitudinal, Patient-Centered Care Plan Across the Continuum of Care

HIT systems respond to the challenges associated with a fragmented healthcare system, which are extensively documented and recognized as barriers to providing high-quality, cost- effective, compliance with regulatory and legal mandates, and receiving appropriate reimbursement (McCauley & Mayo, n.d.). HIT systems are designed to improve communication between providers and assess for health literacy, personal risk behaviors, and socioeconomic determinants in the chronically ill.

There are numerous people in the United States with chronic illnesses who have low health literacy and engage in risky behaviors such as smoking, illegal substance use, and a lack of exercise with a healthy diet. In a study by Boersma, et al., 2020, in the year 2018, 51.8% (129 million)of civilian, noninstitutionalized adults had been diagnosed with at least 1 of 10 selected chronic conditions. More precisely, 24.6 percent (61 million) of adults had at least one chronic disease, while 27.2 percent (68 million) had at least two (Boersma et al., 2020). Along with risky behavior, there are also socioeconomic factors that will affect healthcare outcomes such as financial burden, education level, and the location of the home (many live in food deserts). HIT systems like EPIC gather data to coordinate care planning to include not only medical needs but also socioeconomic determinants that will impact the patient care plan, thus promoting an optimal outcome that is specifically designed for the patient (McCauley & Mayo, n.d.).

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Ways Data Reporting is Specific to Client Behaviors Can Shape Care Coordination

Health HIT systems will interface interdisciplinary evaluations such as Social Work, Rehab Therapist (PT/OT), consults for specialist such as Infectious Diease. Once completed in the EHR, both the MD and Care Coordinator will know how to create a discharge plan that is specific to the patient. The Social Determinants of Health (SDOH) is a best practice alert for SW to identify patient-specific barriers to a safe post-acute care discharge. The SDOH Wheel is divided into ten categories, each reflecting a factor that might affect health: financial constraints, transportation requirements, alcohol use, depression, domestic violence, support networks, physical activity, tobacco/cigarette use, stress, and food insecurity (Johns Hopkins Medicine & Nitkine, 2019). The need for intervention from SW is based on the patients’ response to questions and a provider referral. All disciplines are able to visualize the patient’s answers and adjust recommendations according the patient’s needs. This new Epic feature highlights the importance of assessing SDOH during clinical encounters using a team-based approach by addressing these important factors, which can help reach the ultimate goal of improving health outcomes of our patients (Johns Hopkins Medicine & Nitkine, 2019). Based on the interdisciplinary assessments, Marta will benefit from a consult from Social Work for her recent trauma, four weeks stay in rehabilitation and assistance with notifying her college of the traumatic experience she has endured. Reviewing rehab therapy and infectious diease recommendations, the Care Coordinator will send referrals to outpatient therapy, find a primary care provider and set the follow-up appointments with Trauma-Ortho, Infectious Disease. SW will assist the Care Coordinator with confirming Marta’s housing status with her family, coordinate the home care needed and determine Marta’s transportation to her appointments for follow-up and therapy services. Marta will be educated on how to access the hospital patient portal and demonstrate how to ask provider questions, request medication refills and follow her lab work. Finally, Care Coordination’s post-discharge call to Marta will confirm a seamless discharge and identify any issues to prevent readmission to the hospital with in 30 days of discharge. Coordination and delivery of safe, high-quality care need both internal and cross-organizational, disciplinary efficient HIT systems for optimal patient outcomes (Rosen et al., 2018).

Client Data Collection and Its Positive Influence on Health Incomes

Health information technology (HIT) serves as a platform for a variety of tasks essential for high-quality, integrated care, including the following: facilitates communication among providers who collect the patients data and making it shareable and available to all stakeholders (McCauley & Mayo, n.d.). The barrier of fragmented care that is delivered in silos is removed when the interdisciplinary team has access to the patient’s health data that is collected by various providers. HIT systems may bring together individual components for the appropriate provider and/or patient/family member and delivering the right information that helps individuals establish and accomplish their health and wellness objectives throughout the continuum of care (McCauley & Mayo, n.d.). The team for Marta was able to read the recommendations of the providers on her case prior to the weekly discharge meeting, speak to the specific goals set for Marta and plan appropriately for Marta’s success. Utilizing the EHR for multidisciplinary weekly meetings improve efficiency in healthcare delivery, minimizes cost by decreasing repetitive testing, omission of care which results in smooth transitions of care and reduces readmission to the hospital. Under the domain “Care Coordination/Patient Safety” CMS gives “ACO-8 Risk-Standardized, All Condition Readmission” as a quality measure benchmark (Centers For Medicare & Medicaid Services [CMS], 2020, Appendix A, p. 4). HIT systems “transform culture and practice, with workflow integration that elevates health information technology from data gathering to organization and interpretation” allowing hospital systems to meet or exceed this benchmark (McCauley & Mayo, n.d.).

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Conclusion

With today’s interdisciplinary discharge planning meeting, all providers were able to articulate sound recommendations for Marta Rodriguez. It was unanimously decided the evaluation from Social Work played a pivotal role in her success. The team was able to see and understand Marta’s social determinants of health was primary family support who will assist her in getting to her follow-up appointments and outpatient therapy sessions and psycho-social support from her traumatic experience. All team members offered reasonable care planning and ensured Marta and family was in agreement of her plan. The impact of HIT systems on care coordination results in an overall enhanced patient experience as a result of symptomatic improvement, more efficient processes, and a personal relationship with healthcare providers.

References

Boersma, P., Black, L. I., & Ward, B. W. (2020). Prevalence of multiple chronic conditions among us adults, 2018. Preventing Chronic Disease, 17, 1–4. https://doi.org/10.5888/pcd17.200130

Centers for Medicare and Medicaid Services. (2022, January 4). Consumer assessment of healthcare providers & systems (cahps). cms.gov. https://www.cms.gov/Research- Statistics-Data-and-Systems/Research/CAHPS

Centers For Medicare & Medicaid Services. (2020). Medicare shared savings program quality measure benchmarks for the 2020/2021 performance years [White Paper]. https://www.cms.gov/files/document/20202021-quality-benchmarks.pdf

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Institute of Medicine (US) Committee on Quality of Health Care in America. (2000). To err is human (L. T. John, J. M. Corrigan, & M. S. Donallson, Eds.). National Academies Press. https://doi.org/10.17226/9728

Johns Hopkins Medicine & Nitkine, K. (2019, November 14). A new way to document social determinants of health. https://www.hopkinsmedicine.org/office-of-johns-hopkins- physicians/best-practice-news/a-new-way-to-document-social-determinants-of-health. https://www.hopkinsmedicine.org/office-of-johns-hopkins-physicians/best-practice- news/a-new-way-to-document-social-determinants-of-health

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