Complete an interactive simulation that includes interviews of a patient, family members, and experienced health care workers. Then, develop a care coordination strategy and a care plan for the patient based on the information gathered from the interviews.

Introduction
Note: Each assessment in this course builds on your work from the preceding assessment; therefore, complete the assessments in the order in which they are presented.

Whether designing care plans directed by patients\’ needs and preferences, educating patients and their families at discharge, or doing their best to facilitate continuity of care for patients across settings and among providers, registered nurses use accredited health care standards to realize coordinated care. This assessment provides an opportunity for you to explore health care standards with respect to the quality of care, investigate opportunities and challenges in care coordination, and develop a proactive, patient-centered care plan.

The National Strategy for Quality Improvement in Health Care (2011) focuses on improving patient care, maximizing health resources, and reducing preventable hospital readmissions. Care coordinators reduce readmissions of those suffering from chronic conditions (such as congestive heart failure, pneumonia, asthma, and diabetes) and are responsible for providing quality care in a fiscally responsible manner. While this may seem a reasonable task, shifting the way we use health care resources can be a challenge. Consequently, you must be cognizant of effective strategies for reducing preventable readmissions and understand the barriers that nurses face when coordinating care for patients with chronic illnesses.

Reference
Agency for Healthcare Research and Quality. (2011). 2011 report to Congress: National strategy for quality improvement in health care. AHRQ. https://www.ahrq.gov/workingforquality/reports/2011-annual-report.html

Note: Complete the assessments in this course in the order in which they are presented.

Preparation
As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.

To what extent does a needs assessment support nursing diagnoses?
Which standards or benchmarks drive outcomes in your current professional practice?
What action might you take in response to care plan goals or outcomes that are not being met?
To prepare for this assessment, complete the following simulation:

Vila Health: Care Coordination Scenario I.
In this simulation, you will obtain the information needed to develop a care coordination strategy for Mrs. Snyder and her family. You may use an intervention developed as part of your first assessment. Locate applicable current standards and benchmarks as you determine the best way to develop this strategy.

Note: Remember that you can submit all or a portion of your draft to Smarthinking for feedback before you submit the final version of this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.

Requirements
Develop a proactive, patient-centered care plan for the patient, using the information gained from your simulated interviews. Focus on care coordination and national care coordination initiatives.

Care Plan Format
Use the Patient Care Plan Template [DOCX] provided.

Supporting Evidence
Cite 3–5 sources of scholarly or professional evidence to support your plan.

Developing the Care Plan
The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your care plan addresses each point, at a minimum. Read the Patient Care Plan Scoring Guide to better understand how each criterion will be assessed.

Assess a patient’s condition from a coordinated-care perspective.
Consider the full scope of the patient’s needs.
Include 3–5 pieces of data (subjective, objective, or a combination) that led to a nursing diagnosis.
Develop nursing diagnoses that align with patient assessment data.
Write two goal statements for each diagnosis.
Ensure goals are patient- and family-focused, measurable, attainable, reasonable, and time-specific.
Consider the psychosociocultural aspect of care.
Determine appropriate nursing or collaborative interventions.
List at least three nursing or collaborative interventions.
Provide the rationale for each goal or outcome.
Explain why each intervention is indicated or therapeutic.
Cite applicable references that support each intervention.
Evaluate care coordination outcomes according to measures and standards.
Indicate if the goals were met. If they were not met, explain why.
Describe how you would revise the plan of care based on the patient’s response to the current plan.
Support conclusions with outcome measures and professional standards.
Write clearly and concisely, using correct grammar and mechanics.
Express your main points and conclusions coherently.
Proofread your writing to minimize errors that could distract readers and make it difficult to focus on the substance of your plan.
Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.
Portfolio Prompt: You may choose to save your patient care plan to your ePortfolio.

Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

Competency 1: Develop patient assessments.
Assess a patient\’s condition from a coordinated-care perspective.
Develop nursing diagnoses that align with patient assessment data.
Competency 3: Evaluate care coordination plans and outcomes according to performance measures and professional standards.
Evaluate care coordination outcomes according to measures and standards.
Competency 4: Develop collaborative interventions that address the needs of diverse populations and varied settings.
Determine appropriate nursing or collaborative interventions.
Explain why each intervention is indicated or therapeutic.
Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
Write clearly and concisely, using correct grammar and mechanics.
Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.

Evidence-Based Population Health Improvement Plan

Student’s Name

Institutional Affiliations

Evidence-Based Population Health Improvement Plan

Registered nurses are charged with the responsibility of developing care plans that will ensure that their patients receive coordinated care that will adequately address their healthcare needs. Patients might have numerous health needs some of which may not come out clearly from the presented history. Therefore, the registered nurse needs to interview the patient further, interrogate his or her family members, and question experienced healthcare workers in order to gather adequate information to be able to make an accurate nursing diagnosis (Dains et al., 2019). The nurse can use the information gathered from such interviews to develop a care plan that encourages coordination among healthcare providers. Registered nurses apply accredited health care standards to realize coordinated care for patients and their families. For example, the National Strategy for Quality Improvement in Health Care emphasizes the importance of care coordination among healthcare providers in the inpatient settings and at home in order to make health care safer for patients. Such coordination also maximizes the use of health resources and reduces preventable hospital readmissions (Agency for Healthcare Research and Quality, 2016). The purpose of this assessment is to develop a care coordination strategy for Mrs. Snyder and her family based on the information gathered after interviewing her, experienced healthcare workers, and her family members.

Summary of the Case

The given case study is for a 56-year-old female patient called Rebecca Snyder. Mrs. Snyder was admitted to SAMC for uncontrolled diabetes and hyperglycemia. She has also been diagnosed with ovarian cancer. Mrs. Snyder is stable enough to be discharged. The physician has recommended that she starts chemotherapy and radiation as an outpatient to manage her cancer. However, she needs help from a team of experienced healthcare professionals to address potential red flags that might prevent her from achieving the desired health outcomes. She is also the sole caregiver at home with the responsibility of caring for his 87-year-old mother, her husband David, and their two teenage children who are currently at home. Another potential red flag is that Mrs. Snyder has not been treating her diabetes sufficiently. In order to identify effective collaborative interventions to address Mrs. Snyder’s health needs, the nurse should begin by assessing her condition from a coordinated care perspective.

Assessment of the Patient’s Condition

Full Scope of the Patient’s Needs

Mrs. Snyder has a number of health needs that require coordinated care to effectively be addressed. She needs assistance on how to manage diabetes and hyperglycemia, how to manage ovarian cancer, how to take medications while at home, how to reduce caring responsibilities at home, and to understand the benefits of the recommended treatment interventions. According to Jasemi et al. (2017), understanding the patient’s religious and cultural perceptions regarding health and treatment is an essential step towards providing holistic patient care. Therefore, additional health needs that the nurse should help Mrs. Snyder to address concern management of mental health and addressing her spiritual as well as cultural values that might have negative effects on health outcomes.

Subjective and Objective Data

Mrs. Snyder’s subjective and objective data support the identified health needs. For instance, the given subjective data indicates that Mrs. Snyder was admitted due to uncontrolled diabetes and hyperglycemia. Objective findings that support this information indicate that c/o hyperglycemia ranging from 230 to 389 for over 10 days, frequent urination, malaise, and mild abdominal discomfort. Objective data that confirms the presence of ovarian cancer include radiologic studies/ abdominal ultrasound that revealed approximately 450 ml of peritoneal fluid and blood work results as follows: CA-125-1500 U/ml human chorionic gonadotropin (HCG): 6241 alpha-fetoprotein (AFP): 997 Paracentecis lactate dehydrogenase (LDH): Above normal @ 480U/L. Subjective data further indicates that Mrs. Snyder is experiencing challenges with medication, especially anti-anxiety medications which cause fatigue. Her increased caring responsibilities for her elderly mother, her husband, and children are influenced by her belief that she is the one who can give them appropriate care and by the Orthodox Jewish culture that defines gender roles including what men and women should do and should not do as far as completing domestic chores is concerned. Furthermore, Mrs. Snyder has limited knowledge regarding the benefits of some of the recommended treatment options such as surgery which she claims might cause unnecessary pain.

Nursing Diagnoses

A number of nursing diagnoses are aligned with Mrs. Snyder’s assessment data. They include; risk for unstable blood glucose level/hyperglycemia, deficient knowledge, caregiver role strain, and ineffective medication management/medication non-adherence (Dains et al., 2019). Addressing these nursing diagnoses will help Mrs. Snyder to achieve a good quality of life.

Goal Statements and Consideration of Psycho-sociocultural Aspects of Care

The nurse should set patient- and family-focused, measurable, attainable, reasonable, and time-specific goals that will help in establishing whether the identified nursing diagnoses have been met. Additionally, the nurse should consider the psycho-sociocultural aspect of care when developing these goals. The psycho-sociocultural aspects of care that the nurse has considered include the fact the patient is of a female gender, a Jewish, who believes in traditions with respect to gender roles, and the fact that she is stressed by her son’s drinking behavior (Schwenker et al., 2021). Specific goal statements for each of the identified nursing diagnoses are as follows;

• Risk for unstable blood glucose level
• To be able to have reduced and stable blood glucose levels of between 90-110 mg/dl within a period of two weeks
• To be able to maintain a healthy diabetes diet within a period of 1 week
  • Deficient knowledge
• To be able to comprehend the benefits of the recommended treatment interventions as soon as possible
• To be able to start chemotherapy and radiation as soon as possible
  • Caregiver role strain
• To distribute caregiving roles among family members as soon as possible.
• To enroll Mrs. Snyder’s mother in a nursing home within a period of 1 week.
  • Ineffective medication management/medication non-adherence
• To understand the side effects of the prescribed drugs and how to address them as soon as possible.
• To be able to adhere to the prescribed regimen and have stable mental health within a period of 1 week.

Appropriate Nursing and Collaborative Interventions, Their Rationale, and Intended Therapeutic Benefits

Collaborative interventions will enhance the achievement of nursing care goals identified above. The specific collaborative interventions appropriate for Mrs. Snyder include; working with a gynecologic oncologist to ensure effective management of ovarian cancer, collaborating with a diabetes educator to help the patient to manage her blood sugar, working with a social worker to educate the patient about treatment risks and benefits and to address psycho-sociocultural issues, and to work with family members to address caregiver role strain experienced by Mrs. Snyder. These interventions are aligned with the National Strategy for Quality Improvement in Health Care standards which require nurses to provide care that focuses on improving patient care, maximizing health resources, and reducing preventable hospital readmissions (Agency for Healthcare Research and Quality, 2016).

Evaluation of Care Coordination Outcomes and Conclusion

Nurses usually work with their patients to enhance the attainment of the documented goals of care. Nursing care interventions are usually evaluated based on specific measures. Following an interview with Mrs. Snyder, her healthcare providers, David his husband, and Avi his son, it is evident that the documented nursing goals were not met. It is the nurse’s responsibility to ensure that these goals are met (Park, 2021). Therefore, instead of revising the plan, it would be appropriate to maintain it as it is and continue monitoring the patient for another two weeks.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

Agency for Healthcare Research and Quality. (2016). National Strategy for Quality Improvement in Health Care (continued). https://www.ahrq.gov/workingforquality/about/agency-specific-quality-strategic-plans/nqs3.html

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Jasemi, M., Valizadeh, L., Zamanzadeh, V., & Keogh, B. (2017). A concept analysis of holistic care by hybrid model. Indian Journal of Palliative Care, 23(1), 71–80. https://doi.org/10.4103/0973-1075.197960

Park, B. M. (2021). Effects of nurse-led intervention programs based on goal attainment theory: a systematic review and meta-analysis. Healthcare (Basel, Switzerland), 9(6), 699. https://doi.org/10.3390/healthcare9060699

Schwenker, R., Kroeber, E. S., Deutsch, T., Frese, T., & Unverzagt, S. (2021). Identifying patients with psychosocial problems in general practice: a scoping review protocol. BMJ Open, 11(12): e051383. doi: 10.1136/bmjopen-2021-051383. PMID: 34930731; PMCID: PMC8689158.