NURS FPX 6614 Assessment 4 Improving Care Coordination

The main goal of care coordination is to satisfy patients’ needs and preferences in the delivery of high-quality, high-value health care. This suggests that the patient’s needs and desires are well known and communicated at the proper time to the right individuals, and the information is used to guide the delivery of safe, appropriate, and effective care (Agency for Healthcare Research and Quality, 2018). Healthcare is constantly evolving, and to keep up with the constant demands of the population and communities, we must continue to strive for ways of improving. Today we will examine how to improve the discharge planning process in the nursing unit as well as examine the elements of patient assessment while using the appreciative inquiry method.

While there are many elements of the patient assessment that can vary between settings, the main elements in an inpatient setting are the admission with a physical exam, the continued care and assessment during admission, and the discharge process. The admission process is the most crucial for data accuracy. Electronic medical records have assisted modern-day nursing with ensuring data accuracy and integrity. Maintaining data quality is a difficult but necessary task. In order to achieve consistent and reliable healthcare data, organizations must constantly manage data quality so that they can trust their data and enable quicker and more knowledgeable decisions. Data integrity in care coordination is extremely important as it is used to identify and track patients from one level of care to another. Ensuring the integrity of health is important because healthcare providers use the data to make decisions regarding patient care.

The appreciative inquiry model is designed to seek stakeholders and other healthcare professionals in self-determined change. As we look for change, we can review the AI below:

NURS FPX 6614 Assessment 4 Improving Care Coordination

Discovery: There are many elements here at Vila Health that promote positive and supportive care coordination. While reviewing the care coordination process at Vila Health, the team was noted to have excellent communication skills, teamwork, creating a proactive care plan, incorporating health information technology in the form of electronic medical records, and being about to provide a full range of health care services and providers. The care coordination goal was noted by attempting to improve health outcomes by ensuring the care from providers was delivered effectively. Incorporating the elements listed above ensures organized patient care, and sharing information among all team members has the ability to achieve safer, more cost-effective care (Agency for Healthcare Research and Quality, 2018).

Dream: Isn’t it the dream for every population to receive the best, most effective, and most efficient health care at significant cost savings for the organization? Proposing a discharge planning guide within the electronic medical records (EMR) would be an idealistic and realistic to work towards the dream. EMR system is already in place to help healthcare professionals communicate and exchange updates on the patient’s health. It is typically reported that it is the key function of providing care coordination. At times it is very hard for the interprofessional team to meet all together to discuss patient concerns. This discharge tool will alert everyone on the case that the patient is ready for discharge. The team then has the ability to enter notes regarding their disciplines and the recommended course of action. The case manager then is able to get a full picture of what is needed at discharge all within the EMR. The IDEAL (Include, Discuss, Educate, Assess, and Listen) discharge planning tool can be uploaded to the EMR for all team members to address and provide suggested feedback. Evidence shows that nearly twenty percent of patients experience an adverse event within three weeks of discharge, and another study notes that nearly twenty percent of Medicare patients are hospitalized within thirty days of discharge (Kazemi, Mosleh, & Dierks, 2017). The research shows that this discharge planning tool is needed.

NURS FPX 6614 Assessment 4 Improving Care Coordination

Design: Care coordination relies on accurate data for patient care. All data that is entered into the EMR and reviewed by clinicians must be accurate. The care coordinator is responsible for making sure the data obtained from the patient, family, and medical providers are protected with privacy and confidentiality, which is essential in maintaining a trusted relationship between the health care providers and patients. This is a necessary and integral piece in professional practice (American Nurses Association, 2015). The information that is obtained from the patient is entered into the EMR system and secured with a fingerprint login as well as organizational system firewalls.

Destiny: Incorporating the IDEAL discharge planning tool into the EMR system will be efficient and cost-effective for the healthcare organization. Waste will be reduced as all items will be loaded electronically. The patient’s privacy will be recognized as they will also have access to the discharge information located in the electronic medical home tool in the EMR. The discharge planning tool will allow all healthcare professionals to provide their recommendations for discharge which will provide safe care with positive health outcomes for the patient. The mission of our organization is to be a leader, a partner, and an advocate in the creation of innovative health and wellness. A discharge planning tool will be the wellness solution that improves the lives of the patients and communities we serve.

References

Agency for Healthcare Research and Quality. (2018, August). Care Coordination. Retrieved from https://www.ahrq.gov/professionals/prevention-chronic- care/improve/coordination/index.html

American Nurses Association. (2015, June). American Nurses Association Position Statement on Privacy and Confidentiality. Retrieved from https://www.nursingworld.org/~4ad4a8/globalassets/docs/ana/position-statement- privacy-and-confidentiality.pdf

Kazemi, R., Mosleh, A., & Dierks, M. (2017). A Hybrid Methodology for Modeling Risk of Adverse Events in Complex Health Care Settings. Risk Analysis, 37(3), 421- 440. doi:10.1111/risa.12702

For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 (attached below ABOUT DEPRESSION) using best practices found in the literature.

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