NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Name

Capella University

NURS-FPX 6612 Health Care Models Used in Care Coordination

Prof. Name

Date

Patient Discharge Care Planning

Health Information Technology (HIT) refers to the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of healthcare information, data, and knowledge for communication and decision-making. It encompasses electronic health records (EHRs), health information exchange (HIE), telemedicine, and other technologies aimed at improving healthcare quality, efficiency, and patient outcomes through the use of information and communication technologies (Sheikh et al., 2021).

The assessment also covers that client records, facilitated by HIT, ensure accuracy, completeness, and data reliability, driving Marta’s care coordination, management, efficiency, and innovation. By utilizing HIT systems, the healthcare team ensures Marta’s records accurately reflect her behaviors, allowing for personalized and evidence-based decision-making to improve her health outcomes. Through HIT-enabled data reporting and collaboration, Marta’s care is seamlessly coordinated, efficiently managed, and innovatively tailored to her needs, ultimately enhancing her overall care experience and health outcomes.

Scenario

Marta Rodriguez, a native of New Mexico who recently relocated to Nevada to live with her aunt and uncle. Marta Rodriguez attended a university as a freshman. Following the accident, she underwent antibiotic treatment and multiple surgeries for a systemic infection during a four-week hospital stay, as Marta’s primary language is Spanish. As her senior care coordinator, I will ensure that effective discharge care planning must prioritize clear communication and coordination among interdisciplinary team members. Utilizing informatics tools can streamline information sharing, ensuring Marta’s safe and successful transition with her student health insurance plan. 

Longitudinal Patient Care Plan

To effectively provide a patient-centered longitudinal care plan across the care continuum for Marta, the interprofessional team at Sacred Heart Hospital will utilize various elements of HIT. Electronic Health Records (EHRs) will be central in this process, serving as a comprehensive repository of Marta’s medical history. By integrating information about Marta’s accident, surgeries, medications, and treatment plans, EHRs ensure continuity of care across different healthcare settings. This aligns with the Triple Aim’s goal of improving the patient experience by ensuring that Marta’s care is consistently informed by her medical history, thus enhancing her overall experience and outcomes (Reza et al., 2020). Care coordination platforms, including CareTeam, CareCognize, and CareMessage, will ensure seamless communication and collaboration among team members. These platforms allow for real-time information sharing, appointment coordination, and the development of individualized care plans (de Witt et al., 2020). Care coordination platforms support patient-centered care and enhance Marta’s healthcare experience.

Specific technologies will facilitate ongoing monitoring of Marta’s health, especially post-discharge. These technologies include remote patient monitoring devices, telemedicine platforms, and telehealth monitoring systems. Remote patient monitoring devices can access vital signs like blood pressure and heart rate, while telemedicine platforms enable virtual consultations with healthcare providers (Coffey et al., 2022). Telehealth monitoring systems offer remote monitoring equipment installed in the patient’s home to detect falls or track medication adherence. Allowing healthcare providers to intervene promptly. By utilizing telehealth and remote monitoring, the team can actively engage in proactive care management, thus reducing the likelihood of readmission within 48 hours of discharge (Coffey et al., 2022). This approach supports the Triple Aim’s goal of improving population health by preventing unnecessary hospital readmissions and promoting better health outcomes for Marta. 

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Patient portals like MyChart or Epic’s MyHealth offer Marta an avenue for active engagement in her care. Marta can access her medical records through the portal, review treatment plans, communicate with healthcare providers, and schedule appointments. Patient portals promote patient-centered care by empowering Marta to take an active role in her care and improving patient experience (Avdagovska et al., 2020). Marta’s ability to access her health information and communicate with her healthcare team enhances her engagement in her care, leading to better outcomes and satisfaction.

Decision support systems provide evidence-based guidance to healthcare providers, ensuring Marta receives appropriate care. These systems analyze data to provide recommendations for diagnosis, treatment options, and medication management, thus supporting the interprofessional team in making informed decisions. By utilizing decision support systems, the team can ensure that Marta receives personalized, evidence-based care tailored to her specific needs, thereby improving the quality and safety of her care (Sutton & Pincock, 2020). This approach brings in line with the Triple Aim’s goal of reducing per capita costs by optimizing resource utilization and avoiding unnecessary interventions.

Data Reporting Pertinent to Client Behaviors

Care coordination, clinical effectiveness, care management, and interprofessional innovation are just a few healthcare delivery areas significantly impacted by data reporting tailored to individual client behaviors like Marta’s.

• Data reporting on client behaviors enables more effective care coordination by providing insights into individual needs and preferences. For instance, if Marta’s data indicates irregular medication adherence, care teams can intervene promptly to provide support, ensuring better coordination between providers and Marta (Ogundipe, 2024). This personalized approach improves communication among healthcare professionals and enhances Marta’s overall care experience.
• Data reporting enhances care management by providing insights into the effectiveness of current treatment plans and interventions. For instance, monitoring Marta’s behaviors helps care teams identify areas for improvement and adjust treatment plans accordingly (World Health Organization, 2021). If data reports indicate low medication adherence, for example, care teams can intervene promptly to improve compliance, thus enhancing the effectiveness of Marta’s care management.

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

• Data reporting contributes to clinical efficiency by streamlining processes and optimizing resource allocation. For instance, by analyzing Marta’s behaviors, such as her utilization of healthcare services and medication adherence, the care team can identify patterns and trends that may indicate areas of inefficiency (Tolley et al., 2023). Suppose data reports reveal frequent emergency room visits due to medication non-adherence. In that case, the care team can implement interventions to improve Marta’s adherence and reduce unnecessary healthcare utilization, thus optimizing clinical efficiency.
• Data reporting on Marta’s behaviors fosters interprofessional innovation by facilitating collaboration and knowledge sharing among healthcare providers. For instance, by sharing insights derived from data analysis, interdisciplinary teams can collaborate to develop innovative care models and interventions tailored to Marta’s needs (McLaney et al., 2022). Suppose data reports highlight challenges in Marta’s transition from hospital to home. In that case, the care team can work together to develop a comprehensive discharge plan that addresses her specific needs, thus promoting a seamless transition and reducing the risk of readmission.

Several criteria can be considered to evaluate the quality of the data. Firstly, accuracy ensures that the data accurately reflects Marta’s behaviors and experiences. Completeness ensures that all relevant data points related to Marta’s behaviors are captured, providing a comprehensive view of her health status. Reliability assesses the consistency and stability of the data over time, while relevance evaluates the significance of the data in informing care decisions and interventions specific to Marta’s needs (Rumisha et al., 2020). By assessing data against these criteria, healthcare providers can use high-quality data to effectively drive Marta’s care coordination, management, efficiency, and innovation initiatives. 

Using Client Records to Positively Influence Health Outcomes

Through the use of HIT, information gathered from client records plays a critical role in improving health outcomes by offering thorough insights into the client’s medical history, progress with treatment, and current state of health. In Marta’s case, her medical records contain vital information about past medical conditions, ongoing treatments, and surgical procedures. These records enable healthcare providers to tailor Marta’s care plan precisely to her needs, ensuring a more effective and personalized approach to treatment using HIT systems (Aminabee, 2024). Client records ensure seamless continuity of care by providing all healthcare providers involved in Marta’s treatment access to the same information through HIT. It enables smooth transitions between different care settings and reduces the risk of errors or duplications in treatment (Vos et al., 2020). For example, if Marta’s primary care physician needs to refer her to a specialist, her electronic health records ensure that the specialist has complete information about her medical history and current treatments, facilitating informed decision-making and avoiding potential treatment conflicts. 

Client records empower evidence-based decision-making by providing data-driven insights into effective treatment strategies made possible through HIT systems. Analyzing trends in Marta’s health data, such as lab results, medication adherence, and vital signs, allows the interprofessional team to identify areas for intervention and adjust her care plan accordingly using HIT tools (Ruaya, 2023). For instance, if Marta’s blood glucose levels consistently show poor control, her care team can develop a personalized management plan focusing on diet, exercise, and medication adjustments, leading to better health outcomes with HIT.

Assumptions

Based on the assumption, care coordinators conclude that leveraging HIT tools leads to more effective care coordination, personalized treatment plans, and improved health outcomes for Marta. In coordinating their findings, the interprofessional team members utilize HIT systems, inputting assessments, notes, and recommendations into Marta’s electronic health record (EHR). This ensures all team members have real-time access to information, allowing them to review Marta’s progress and treatment plans (Okolo et al., 2024). Additionally, secure messaging and communication platforms integrated into the HIT system facilitate information exchange and collaborative discussions about Marta’s case, enhancing the quality of care provided through HIT-enabled coordination (Machon et al., 2020). client records and HIT systems enable comprehensive understanding, continuity of care, and collaborative decision-making, optimizing Marta’s health outcomes. Effective HIT tool utilization ensures the best possible care for Marta in a collaborative environment.

Conclusion

The utilization of HIT in Marta’s care plan ensures accuracy, completeness, reliability, and relevance of data, driving effective care coordination, management, efficiency, and innovation. Through HIT-enabled systems, patients medical records provide a comprehensive view of her health status, enabling personalized and evidence-based decision-making by the interprofessional team. This approach fosters seamless communication and collaboration among healthcare providers, resulting in tailored interventions and improved health outcomes. By evaluating data against established criteria, HIT empowers the team to optimize Marta’s care experience, enhancing the quality and efficiency of healthcare delivery.

References

World Health Organization. (2021). Global patient safety action plan 2021-2030: Towards eliminating avoidable harm in health care. In Google Books. World Health Organization. https://books.google.com/books?hl=en&lr=&id=csZqEAAAQBAJ&oi=fnd&pg=PR7&dq=+data+reporting+monitoring+of+patients+helps+care+teams+identify+areas+for+improvement+and+adjust+treatment+plans+accordingly+in+healthcare&ots=xKRZb1kkxy&sig=1xXu1N2Sv37cO1_xknrbmZM03uI 

Aminabee, S. (2024). The future of healthcare and patient-centric care: Digital innovations, Trends, and Predictions. Www.igi-Global.com; IGI Global. https://www.igi-global.com/chapter/the-future-of-healthcare-and-patient-centric-care/339355 

Avdagovska, M., Ballermann, M., Olson, K., Graham, T., Menon, D., & Stafinski, T. (2020). Patient portal implementation and uptake: Qualitative comparative case study. Journal of Medical Internet Research, 22(7), e18973. https://doi.org/10.2196/18973 

Coffey, J. D., Christopherson, L. A., Williams, R. D., Gathje, S. R., Bell, S. J., Pahl, D. F., Manka, L., Blegen, R. N., Maniaci, M. J., Ommen, S. R., & Haddad, T. C. (2022). Development and implementation of a nurse-based remote patient monitoring program for ambulatory disease management. Frontiers in Digital Health, 4(2). https://doi.org/10.3389/fdgth.2022.1052408 

de Witt, A., Matthews, V., Bailie, R., Garvey, G., Valery, P. C., Adams, J., Martin, J. H., & Cunningham, F. C. (2020). Communication, collaboration and care coordination: The three-point guide to cancer care provision for aboriginal and torres strait islander Australians. International Journal of Integrated Care, 20(2). https://doi.org/10.5334/ijic.5456 

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Machon, M., Knighten, M. L., & Sohal, J. (2020). Improving clinical communication and collaboration through technology: Nurse Leader, 18(5), 481–486. https://doi.org/10.1016/j.mnl.2020.06.003 

McLaney, E., Morassaei, S., Hughes, L., Davies, R., Campbell, M., & Prospero, L. D. (2022). A framework for interprofessional team collaboration in a hospital setting: Advancing team competencies and behaviours. Healthcare Management Forum, 35(2), 112–117. https://doi.org/10.1177/08404704211063584 

Ogundipe, D. O. (2024). The impact of big data on healthcare product development: A theoretical and analytical review. International Medical Science Research Journal, 4(3), 341–360. https://doi.org/10.51594/imsrj.v4i3.932 

Okolo, C. A., Ijeh, S., Arowoogun, J. O., Adeniyi, A. O., & Omotayo, O. (2024). Reviewing the impact of health information technology on healthcare management efficiency. International Medical Science Research Journal, 4(4), 420–440. https://doi.org/10.51594/imsrj.v4i4.1000 

Reza, F., Prieto, J. T., & Julien, S. P. (2020). Electronic health records: Origination, adoption, and progression. Health Informatics, 183–201. https://doi.org/10.1007/978-3-030-41215-9_11 

Ruaya, P. R. (2023). Data-driven healthcare: evaluating the effectiveness of the patient record management system at RHU-Del Carmen. International Journal of Advanced Research in Science, Communication and Technology, 552–561. https://doi.org/10.48175/ijarsct-12178 

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Rumisha, S. F., Lyimo, E. P., Mremi, I. R., Tungu, P. K., Mwingira, V. S., Mbata, D., Malekia, S. E., Joachim, C., & Mboera, L. E. G. (2020). Data quality of the routine health management information system at the primary healthcare facility and district levels in Tanzania. BMC Medical Informatics and Decision Making, 20(1). https://doi.org/10.1186/s12911-020-01366-w 

Sheikh, A., Anderson, M., Albala, S., Casadei, B., Franklin, B., Richards, M., Taylor, D., Tibble, H., & Mossialos, E. (2021). Health information technology and digital innovation for national learning health and care systems. The Lancet Digital Health, 3(6), 383–396. https://www.sciencedirect.com/science/article/pii/S2589750021000054 

Sutton, R., & Pincock, D. (2020). An overview of clinical decision support systems: Benefits, risks, and strategies for success. NPJ Digital Medicine, 3(1), 1–10. https://doi.org/10.1038/s41746-020-0221-y 

Tolley, A., Hassan, R., Sanghera, R., Grewal, K., Kong, R., Sodhi, B., & Basu, S. (2023). Interventions to promote medication adherence for chronic diseases in India: A systematic review. Frontiers in Public Health, 11. https://doi.org/10.3389/fpubh.2023.1194919 

Vos, J. F. J., Boonstra, A., Kooistra, A., Seelen, M., & van Offenbeek, M. (2020). The influence of electronic health record use on collaboration among medical specialties. BioMed Central Health Services Research, 20(1), 676. https://doi.org/10.1186/s12913-020-05542-6