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Name
Capella University
NURS-FPX 6610 Introduction to Care Coordination
Prof. Name
Date
Esteemed stakeholders and family members. My name is ________, and today’s presentation discusses Mrs. Snyder’s case and the care plans developed to address her chronic health condition. The objective is to inform you about her health status and care plans so we can deliver high-quality, patient-centered care and improve her health outcomes.
The objectives of today’s presentation are:
Rebecca Snyder, a 56-year-old patient, belongs to a traditional Orthodox Jewish family. She has five children, including two teenagers, and the grandmother of seven. Last week, she was admitted to the emergency room at our hospital due to uncontrolled diabetes and high blood sugar levels. During her examination, doctors found additional health issues and, unfortunately, diagnosed her with advanced ovarian cancer. She is the primary caregiver of her family. Thus, her family is unprepared to deal with this severe disease with a limited prognosis.
A comprehensive care plan developed for Mrs. Snyder addresses multiple facets of her health challenges, aiming to stabilize her blood glucose levels, ensure adherence to dietary restrictions, and manage anxiety related to her cancer diagnosis. The primary goal for managing diabetes is to educate her on effective diabetes self-management, mainly focusing on blood glucose monitoring and insulin adjustment. The patient will be instructed about average glucose ranges per the guidelines from the American Diabetes Association (ADA). For instance, average pre-meal glucose should range between 80 to 130 mg/dL, and post-meal glucose levels should be less than 180 mg/dL (American Diabetes Association, n.d.). The plan includes hands-on training and education on recognizing normal glucose levels and adjusting insulin dosages.
This education aims to empower the patient to maintain her blood glucose within target ranges, preventing complications and improving her quality of life (Borges et al., 2024). Another goal is dietary management tailored to the patient’s cultural needs, ensuring compliance with kosher nutritional laws while managing her diabetes. The care plan involves collaboration with a dietitian to provide education on diabetic-friendly kosher foods, meal planning, and identifying emotional eating triggers. Engaging the patient’s family in dietary education ensures collective support for her dietary adherence (Horikawa et al., 2020).
Finally, the care plan addresses the patient’s anxiety, mainly stemming from cancer diagnosis. The plan includes emotional support from the interdisciplinary team, providing clear information about her diagnosis and treatment options. Social workers will ensure empathetic communication, while a list of community counselors will be provided to ensure the patient receives adequate and continuous care.
Regular follow-up appointments are also integral to her emotional well-being and ongoing support (Grassi et al., 2023). The care plan emphasizes patient education, family involvement, and a holistic approach to managing the patient’s complex health needs, ensuring that her physical and emotional health are comprehensively addressed.
Our patient’s transitional care plan is meticulously designed to ensure seamless continuity of care as she moves between different healthcare settings. This plan addresses her complex medical conditions, including advanced ovarian cancer and diabetes. The plan emphasizes accurate transfer of medical records, thorough medication reconciliation, including emergency and advance directive information, incorporating patient feedback, and leveraging community and healthcare resources.
Maintenance of detailed and accurate medical records is central to Mrs. Snyder’s transitional care, encompassing her medical history, diabetes management, previous treatments, and her recent cancer diagnosis. According to the literature, accurate and comprehensive documentation minimizes the risk of medical errors, ensuring informed decision-making by healthcare providers (Subbe et al., 2021). Alongside this, medication reconciliation is a critical process aimed at verifying her current medication list to prevent adverse drug interactions and ensure appropriate treatment and safety during transitions. Similarly, the care plan integrates emergency and advance directive information to ensure that it includes Mrs. Snyder’s resuscitation preferences, desired interventions, and any specific religious or personal beliefs influencing her care.
By documenting these directives, the plan reduces unnecessary interventions and enhances patient satisfaction. Finally, incorporating patient feedback is essential for tailoring the care plan to Mrs. Snyder’s specific needs and preferences. This approach helps identify areas for improvement and ensures a patient-centered care experience (Vat et al., 2019). Additionally, the plan highlights the importance of utilizing community and healthcare resources, such as social support services and outpatient care, to manage her chronic conditions and enhance her quality of life. Integrating these resources reduces hospital readmissions and effectively supports patient transitions (Facchinetti et al., 2020).
Along with these critical elements, effective communication among healthcare providers and community service agencies is crucial for a seamless transition. Timely and accurate information exchange about patient’s health status, treatment plans, and specific needs prevents errors and enhances care continuity (Patel & Landrigan, 2019). Addressing barriers such as incompatible electronic health record systems and inadequate staff training is also critical. Implementing standardized communication protocols and training staff on thorough information transfer are strategies to mitigate these challenges. To further ensure accurate understanding and continuity of care, the plan proposes using advanced digital technologies like blockchain and patient-centered mobile apps. Blockchain can securely track and share patient data across providers. At the same time, a mobile app can empower Mrs. Snyder by providing access to her health records, medication lists, and follow-up plans. These technologies foster real-time updates and active patient participation, enhancing the overall effectiveness of the transitional care plan (Cerchione et al., 2022).
An interprofessional care team is essential for delivering high-quality patient outcomes, particularly for Mrs. Snyder, who requires comprehensive management of advanced ovarian cancer and uncontrolled diabetes. The critical stakeholders to implement these care plans include physicians, nurses, dietitians, pharmacists, social workers, and patient care coordinators. Additionally, family members play a crucial role in supporting healthcare interventions. Each professional brings unique expertise and functions contributing to the overall care strategy, ensuring holistic and patient-centered outcomes.
While physicians are crucial for diagnosing and developing treatment plans for Mrs. Snyder’s cancer and diabetes, prescribing medications, and adjusting treatment regimens based on her progress and test results, nurses are integral in implementing care plans, monitoring patient’s daily health status, administering medications, and providing education on glucose monitoring and insulin administration (Borges et al., 2024). Nurses also offer emotional support and build empathetic relationships, addressing physical and psychological aspects of her well-being.
Additionally, dietitians are essential for managing Mrs. Snyder’s dietary needs and ensuring her meals comply with diabetic guidelines and kosher dietary laws. They also create tailored dietary plans and collaborate with patients’ family members to help maintain their blood glucose levels, vital for cancer treatment efficacy. Here, family members are crucial in improving patient outcomes by participating in health education and creating a supportive home environment that reinforces healthy behaviors and compliance with medical advice (Horikawa et al., 2020). Pharmacists oversee medication reconciliation, provide critical insights into medication management, adjust dosages as needed, and educate Mrs. Snyder on proper medication use, which is crucial for managing her complex health conditions. Finally, social workers and patient care coordinators address the non-medical aspects of Mrs. Snyder’s care, such as coordinating appointments, facilitating access to community resources, and providing support for navigating healthcare systems. This interprofessional approach is critical in achieving high-quality patient outcomes for Mrs. Snyder, ensuring a seamless and effective transition across different care settings.
To effectively coordinate care for Mrs. Snyder’s complex health needs, various stakeholders require tailored information and differing familiarity with care coordination processes. As leaders in treatment planning, physicians require comprehensive data on Mrs. Snyder’s medical history and ongoing progress to make informed decisions. They utilize Electronic Health Records (EHR) to collect patient health information (Fennelly et al., 2020). While proficient in implementing care plans, nurses benefit from clear communication channels and access to patient records for daily monitoring and intervention.
Open communication channels ensure smooth information sharing, enabling nurses to provide holistic patient care (Fennelly et al., 2020). Dietitians need detailed dietary information and ongoing updates on Mrs. Snyder’s health status to adapt meal plans accordingly. Pharmacists rely on accurate medication records and regular updates to optimize drug therapy. Social workers and patient care coordinators require comprehensive knowledge of community resources and effective communication strategies to facilitate seamless transitions and support Mrs. Snyder’s non-medical needs. Family members need education on Mrs. Snyder’s conditions and support in implementing care plans, emphasizing the importance of clear, accessible information for all stakeholders in achieving optimal patient outcomes (Horikawa et al., 2020).
Several factors could significantly influence outcomes for Mrs. Snyder, considering her diagnosis of advanced ovarian cancer coupled with uncontrolled diabetes. Firstly, the extent of disease progression and response to treatment plays a pivotal role. Given the advanced stage of the patient’s cancer, the effectiveness of therapy will directly impact her prognosis. Moreover, disease progression significantly affects patient’s quality of life and health-related outcomes, leading to positive or negative consequences (Marschner et al., 2020). Similarly, achieving glycemic control is paramount in managing her diabetes, as uncontrolled hyperglycemia could exacerbate complications and hinder cancer treatment efficacy.
The level of adherence to prescribed medications and dietary restrictions by Mrs. Snyder and her family also profoundly influences outcomes. Several psychological factors, including stress and anxiety related to her diagnosis, can affect her adherence to treatment plans. Finally, family support and involvement significantly influence her ability to maintain dietary restrictions and manage her overall health, deciding the patient’s health outcomes (Horikawa et al., 2020).
The analysis assumes that Mrs. Snyder has adequate access to healthcare resources, such as timely appointments, medication availability, and proper support systems. It is believed that the success of our care plan and transitional care plan in managing Mrs. Snyder’s conditions relies on effective clinical treatments and holistic care coordination encompassing patient education, emotional support, dietary management, and seamless transitions between healthcare settings. However, uncertain circumstances like individual patient response underscores the importance of ongoing monitoring, personalized interventions, and adaptive care strategies tailored to Mrs. Snyder’s evolving needs. Limited access to specialized care due to geographic or financial constraints might hinder optimal treatment. Finally, potential disruptions in care continuity, such as provider availability between healthcare settings, pose uncertain risks to seamless care delivery.
Implementing continuing care for Mrs. Snyder requires various technological, human, facility, logistical, educational, and emotional support resources.
List of Resources
Several factors influence the determination of this list of resources needed for Mrs. Snyder’s continuing care. While Mrs. Snyder’s case requires a multifaceted list of resources (technological, human, facilitation, logistical, and emotional support resources), the complexity and severity of her medical conditions may impact these resources. Accordingly, the team may require less or more resources to address her health concerns. Moreover, language barriers and financial constraints may impede the availability and applicability of these resources. Furthermore, her treatment choices and level of support influence the required resources, which may be modified according to the patient’s needs and preferences. Thus, the list of resources presented earlier is selected according to the care plans developed for Mrs. Snyder. By addressing these factors thoughtfully and proactively, we can optimize Mrs. Snyder’s treatment outcomes and ensure that she receives holistic, patient-centered care throughout her journey.
Today’s presentation has centered on the goals and scope of care plans, emphasizing the importance of comprehensive and coordinated approaches to patient care. We explored how an interprofessional care team collaborates to deliver high-quality care. Additionally, we thoroughly examined factors influencing patient outcomes, such as disease progression, treatment adherence, and social support, highlighting the need for tailored interventions and ongoing monitoring. In discussing the resources required for implementing ongoing care, we emphasized the significance of medical, logistical, and emotional support tailored to individual patient needs in Mrs. Snyder’s case. To conclude, the presentation underscores the critical role of interdisciplinary collaboration, patient-centered care, and comprehensive resources in achieving optimal patient outcomes and enhancing the quality of care delivery.
American Diabetes Association. (n.d.). The big picture: Checking your blood glucose | ADA. Diabetes.org. https://diabetes.org/living-with-diabetes/treatment-care/checking-your-blood-sugar
Borges, L. P., de Jesus, P. C., de Souza, J. B., Silva, D. M. R. R., Moura, P. H. M., Santos, R. S., … & Silva, E. E. D. (2024). The impact of diabetes education on continuous glucose monitoring in SUS-dependent patients in a Northeastern Brazilian City. Life, 14(3), 320. https://doi.org/10.3390/life14030320
Cerchione, R., Centobelli, P., Riccio, E., Abbate, S., & Oropallo, E. (2022). Blockchain’s coming to hospital to digitalize healthcare services: Designing a distributed electronic health record ecosystem. Technovation, 120(1). https://doi.org/10.1016/j.technovation.2022.102480
Facchinetti, G., D’Angelo, D., Piredda, M., Petitti, T., Matarese, M., Oliveti, A., & De Marinis, M. G. (2020). Continuity of care interventions for preventing hospital readmission of older people with chronic diseases: A meta-analysis. International Journal of Nursing Studies, 101, 103396. https://doi.org/10.1016/j.ijnurstu.2019.103396
Fennelly, O., Cunningham, C., Grogan, L., Cronin, H., O’Shea, C., Roche, M., Lawlor, F., & O’Hare, N. (2020). Successfully implementing a national electronic health record: A rapid umbrella review. International Journal of Medical Informatics, 144. https://doi.org/10.1016/j.ijmedinf.2020.104281
Grassi, L., Caruso, R., Riba, M. B., Lloyd-Williams, M., Kissane, D., Rodin, G., McFarland, D., Campos-Ródenas, R., Zachariae, R., Santini, D., & Ripamonti, C. I. (2023). Anxiety and depression in adult cancer patients: ESMO clinical practice guideline. ESMO Open, 8(2), 101155. https://doi.org/10.1016/j.esmoop.2023.101155
Horikawa, C., Hatta, M., Morikawa, S. Y., Takeda, Y., Takeuchi, M., Fujihara, K., Kato, N., Yokoyama, H., Kurihara, Y., Iwasaki, K., Tanaka, S., Maegawa, H., & Sone, H. (2020). Family support for medical nutritional therapy and dietary intake among Japanese with type 2 diabetes (JDDM 56). Nutrients, 12(9), 2649. https://doi.org/10.3390/nu12092649
Lee, S.-Y., Lee, H., Mtengezo, J., Makin, M., Park, J.-H., & Thompson, L. (2019). Cancer screening and diagnostic tests in global contexts: Case study and concept analysis. Asia-Pacific Journal of Oncology Nursing, 6(1), 86. https://doi.org/10.4103/apjon.apjon_59_18
Marschner, N., Zacharias, S., Lordick, F., Hegewisch-Becker, S., Martens, U., Welt, A., Hagen, V., Gleiber, W., Bohnet, S., Kruggel, L., Dille, S., Nusch, A., Dörfel, S., Decker, T., & Jänicke, M. (2020). Association of disease progression with health-related quality of life among adults with breast, lung, pancreatic, and colorectal cancer. JAMA Network Open, 3(3), e200643. https://doi.org/10.1001/jamanetworkopen.2020.0643
Patel, S. J., & Landrigan, C. P. (2019). Communication at transitions of care. Pediatric Clinics of North America, 66(4), 751–773. https://doi.org/10.1016/j.pcl.2019.03.004
Subbe, C. P., Tellier, G., & Barach, P. (2021). Impact of electronic health records on predefined safety outcomes in patients admitted to hospital: A scoping review. British Medical Journal Open, 11(1), e047446. https://doi.org/10.1136/bmjopen-2020-047446
Vat, L. E., Finlay, T., Warnaar, J. S. T., Fahy, N., Robinson, P., Boudes, M., Diaz, A., Ferrer, E., Hivert, V., Purman, G., Kürzinger, M., Kroes, R. A., Hey, C., & Broerse, J. E. W. (2019). Evaluating the “return on patient engagement initiatives” in medicines research and development: A literature review. Health Expectations, 23(1), 5–18. https://doi.org/10.1111/hex.12951
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