NURS FPX 6610 Assessment 1: Comprehensive Needs Assessment

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Comprehensive Needs Assessment

A full health needs assessment looks at all of a person’s physical, mental, social and environmental needs so that a personalized care plan can be formulated. A complete picture of a patient’s condition requires information to be gathered from different sources including the patient, family members, medical records, and the health care team (Røsvik & Rokstad, 2020). The initial admission of Mr. Ryan to the hospital could have been followed by a proper needs assessment that may have included such information as the difficulties involved in the control of diabetes and the lack of stability in the social support system. NURS FPX 6610 Assessment 1: Comprehensive Needs Assessment: It could also have demonstrated the difficulties he had in reaching appointments. A complete need assessment could have prevented Mr. Ryan from returning to the hospital with the infection that had worsened to sepsis.

NURS FPX 6610 Assessment 1: Current Gaps in Patient Care

Mr. Ryan, a 80-year-old individual with diabetes, was admitted to hospital with a severely infected toe and suffered from sepsis after being discharged due to inadequate home care. A major challenge was that the living environment and support system of Mr. Ryan were not assessed prior to his first discharge to home.The case managers trusted that Mr. Ryan’s wife and nephew would assist him with his care, but they did not verify if they were able or willing to do so. During a complete assessment, these family members would be interviewed directly to check their comprehension and consent with the care plan (Chin et al., 2021).The team could have utilized Caregiver Strain Index or any other instrument to formally assess the capacity of Mr. Ryan’s care givers.

Another part of Mr. Ryan’s care that was subpar was the evaluation of his diabetes control, which resulted in his toe infection. The primary diligence was on treating the disease but a detailed evaluation would have revealed that Mr. Ryan was rationale with taking his medications and doing with the necessary changes in his lifestyle. NURS FPX 6610 Assessment 1: Comprehensive Needs Assessment: Doing this you would have been able to learn this by speaking in detail to the patient and getting feedback from his main care doctor and diabetes educator (Ndjaboue et al., 2020). These holes being found and patched could have enhanced Mr. Ryan’s overall well-being and averted him from reentering the hospital.

Strategy to Gather Additional Data

In order to come up with a comprehensive healthcare strategy for Mr. Ryan, more assessment information will be needed than can be gained from the initial patient interview. All Mr. Ryan needs must be considered, whether medical, functional, social, or environmental, to give him a complete, well-coordinated care. One means through which such information can be obtained is a home visit. The case manager could observe the living situation of Mr. Ryan, what potential risks and hazards are present, and what resources does he have. Standard assessment tools like the Lawton-Brody Instrumental Activities of Daily Living Scale could be used by the case manager to identify the performance of Mr. Ryan and the Home Safety Self-Assessment Tool could be used to find what dangers may exist in the house (Mangiagli et al., 2021). The case manager could also have a conversation with Mr. Ryan’s wife and ask her what she knows, how confident she is about her ability to take care of him, if she is facing any problems or needs that are not being addressed.

Another significant stage would be co-operation with the multidisciplinary health care team of Mr. Ryan.This would also enable to obtain a reliable survey data in their approach. This might involve the checking of his medical records where he has a history of diabetes, the attendant care of his wounds and any other illnesses that might delay his healing. The case manager should also consult the main care physician, diabetes educator, and any consultants assisting in Mr. Ryan’s care for their input and recommendations. Assistance from a wound care nurse and a nutritionist would help in managing the infection of Mr. Ryan and ensuring the best nutrition for healing. (Fettes et al., 2023) Lastly, the case worker will conduct a case conference with representatives from each of the fields in order to share the results of the assessment, set targets and goals, and develop a comprehensive care plan that will address all of Mr. Ryan’s needs. NURS FPX 6610 Assessment 1: Comprehensive Needs Assessment: Employing a methodical interdisciplinary method to evaluation, the case supervisor can ensure the examination of the principal concerns and guarantee that Mr. Ryan obtains well-coordinated, patient-centric care.

NURS FPX 6610 Assessment 1: Factors Affecting Patient Outcomes

There are many social, economic, and interprofessional issues which are likely to exert a significant impact on the health of Mr. Ryan. The social factors include the ageing population and the rising incidences of chronic ailments such as diabetes. The Centers for Disease Control and Prevention (CDC) report that over 34 million Americans have hypergymcemia, and the likelihood rises with age. Being an older person with diabetes, Mr. Ryan is more likely to develop issues like foot infections, which can lead to serious consequences if inadequately handled (ADA, 2023). This indicates that it is vital that older people with chronic diseases get personalized preventive care.

The economic factors, such as the coverage of Mr. Ryan and his out-of-pocket expenditures, can also play a significant role on his outcomes. The principal insurance for people above 65 years is Medicare that covers hospitalizations, proficient nursing facilities, and in-home healthcare (CMS, 2021). Nonetheless, copays and deductibles may continue to be a source of significant financial burden, particularly for individuals who are living on a fixed income. Medicare does not pay for all the services that would be useful to Mr. Ryan, including non-urgent transportation, or home adjustments for safety (Corridori et al., 2023). Fiscal constraints may result in difficulties in obtaining the necessary care and assistance, therefore, the bad results.

Professionals coordination is another essential thing that needs to take place for Mr. Ryan to get the best results. In case of complete patient-centered care design, healthcare personnel such as physicians, nurses, diabetes educators, social workers and/or case managers should be able to communicate with each other and work together effectively (Keshmiri et al., 2020). Communication difficulties or a lack of role definition might lead to improved patient results, more consistent care, and contradictory guidance. For example if Mr. Ryan’s primary care provider and wound care nurse are not communicating with each other regarding his progress and treatment plan, he may heal slowly and be managed differently. NURS FPX 6610 Assessment 1: Comprehensive Needs Assessment: For instance, when someone is transitioning from the hospital to home or a skilled nursing facility, they are called upon to collaborate with other practitioners of various fields (Zorek et al., 2021). The incidence of negative events, readmissions, and stress on part of both patients and carers can be reduced in case of clear and timely communication and well-organized transitional care.

Cause-and-Effect Relationship

The study demonstrates how social, economic, and interprofessional determinants of outcomes are related with the outcome, and how social, economic, and interprofessional determinants affect the outcome. There are relevant, credible evidences of these connections from trustworthy references, like peer-reviewed articles and public health authorities (Zorek et al., 2021). The dialogue reveals a thorough comprehension of these elements and how they relate to each other and the kind of person Mr. Ryan is.

NURS FPX 6610 Assessment 1: Professional Standards

In the case of Mr. Ryan, some outcome measures for patients and care management can be closely associated with performance standards of well-known groups and authorities. E.g. The Centres for Medicare & Medicaid Services (CMS) have developed quality measures for care coordination. These encompass the rate of non-proportioned unplanned hospital readmissions and the percentage of patients who have had a care plan noted in their medical record (50% of patients, 2023). This is done to help improve the coordination of care and make things better for the patient. For Mr. Ryan, primary result indicators could include a holistic diabetes management strategy, wound treatment, and social assistance necessities, effective care coordination among his medical team, and his capability to manage his condition without complications or readmission.

The steps conform to what associations like the National Quality Forum (NQF) recommend be done. It supports interventions promoting patient involvement, transitional care, as well as communication (National Quality Forum, 2021). Using these professional standards to assess results simplifies the determination of how well the care coordination strategies work. By demonstrating how specific outcomes correspond to established guidelines, healthcare personnel can ensure they deliver evidence-based, patient-focused care that aligns with the utmost quality benchmarks.

NURS FPX 6610 Assessment 1: Evidence-Based Practices

In terms of public health, Mr. Ryan must be managed as a whole using a mixed approach patient care.Furthermore, there is a number of empirical practices that uphold this methodology include interdisciplinary cooperation, care strategizing, and patient-centric care (Brooks et al., 2020). As a diverse group of healthcare professionals, encompassing physicians, nurses, diabetes educators, social workers, and case managers, collaborates, Mr. Ryan will attain a thorough comprehension of his requirements and a care strategy harmonizing with all other facets. NURS FPX 6610 Assessment 1: Comprehensive Needs Assessment: This collaborative approach has resulted into improved outcomes for patients, reduced health care costs, and increased satisfaction levels with both patients and providers (Drossman & Ruddy, 2020). As an example, Schot et al. (2020) carried out a very detailed study that demonstrated that the collaboration between professionals from different healthcare settings resulted in better outcomes for the patients. The healthcare groups can also guarantee that patients such as Mr. Ryan receive all the evidence-supported care necessary for health maintenance and prevention of problems by advocating for a team-based approach.

Conclusion

The case of Mr. Ryan illustrates the significance of doing a comprehensive needs assessment, collaboration, and teamwork by professionals from different disciplines to provide client-centric care for elderly individuals with intricate conditions. Recognizing deficiencies in Mr. Ryan’s initial care strategy, such as inadequate assessment of his home setting and support level, healthcare professionals can devise specific methods of obtaining the necessary information and eliminating any obstacles that may impede success.

References

American Diabetes Association. (2023). Home | ADA. Diabetes.org. https://diabetes.org

Brooks, E. M., Winship, J. M., & Kuzel, A. J. (2020). A “behind-the-scenes” look at interprofessional care coordination: How person-centered care in safety-net health system complex care clinics produce better outcomes. International Journal of Integrated Care, 20(2). https://doi.org/10.5334/ijic.4734

Centers for Disease Control and Prevention. (2023, April 18). Type 2 diabetes. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/basics/type2.html#:~:text=About%2038%20million%20Americans%20have

Centers for Medicare & Medicaid Services. (2021). Medicare Diabetes Prevention Program (MDPP) expanded model | CMS. Www.cms.gov. https://www.cms.gov/priorities/innovation/innovation-models/Medicare-diabetes-prevention-program

Chin, Y. F., Huang, T. T., Yu, H.Y., Yang, H.M., & Hsu, B. R. S. D. (2021). Factors related to hospital‐to‐home transitional self‐monitoring blood glucose behaviour among patients with diabetes‐related foot ulcer. International Journal of Nursing Practice, 27(6). https://doi.org/10.1111/ijn.12950

Corridori, L. G., Boesing, M., Ottensarendt, N., Leuppi-Taegtmeyer, A. B., Schuetz, P., & Leuppi, J. D. (2023). Predictors of length of stay, mortality and rehospitalization in COPD patients: A retrospective cohort study. Journal of Clinical Medicine, 12(16), 5322. https://doi.org/10.3390/jcm12165322

Drossman, D. A., & Ruddy, J. (2020). Improving patient–provider relationships to improve health care. Clinical Gastroenterology and Hepatology, 18(7), 1417–1426. https://doi.org/10.1016/j.cgh.2019.12.007

Fettes, L., Bayly, J., Emeka Chukwusa, Ashford, S., Higginson, I., & Maddocks, M. (2023). Predictors of increasing disability in activities of daily living among people with advanced respiratory disease: A multi-site prospective cohort study, England UK. Disability and Rehabilitation, 1–10. https://doi.org/10.1080/09638288.2023.2288673

https://doi.org/10.1136/bmjopen-2019-032762

Keshmiri, F., Jafari, M., Dehghan, M., Raee-Ezzabadi, A., & Ghelmani, Y. (2020). The effectiveness of interprofessional education on interprofessional collaborative practice and self-efficacy. Innovations in Education and Teaching International, 58(4), 408–418. https://doi.org/10.1080/14703297.2020.1763827

Mangiagli, J., Manion, B., Roque, M., & Wasilenski, O. (2021). Evidence supporting the effectiveness of standardized assessments at predicting safe performance of activities of daily living for patients in skilled nursing facilities. School of Occupational Therapy Master’s Capstone Projects. https://soundideas.pugetsound.edu/ot_capstone/47/

National Quality Forum. (2021). NQF: Effective communication and care coordination. Www.qualityforum.org. https://www.qualityforum.org/Topics/Effective_Communication_and_Care_Coordination.aspx

Ndjaboue, R., Chipenda Dansokho, S., Boudreault, B., Tremblay, M.-C., Dogba, M. J., Price, R., Delgado, P., McComber, A. M., Drescher, O., McGavock, J., & Witteman, H. (2020). Patients’ perspectives on how to improve diabetes care and self-management: qualitative study. British Medical Journal Open, 10(4).

Røsvik, J., & Rokstad, A. M. M. (2020). What are the needs of people with dementia in acute hospital settings, and what interventions are made to meet these needs? A systematic integrative review of the literature. BioMed Central Health Services Research, 20(1). https://doi.org/10.1186/s12913-020-05618-3

Schot, E., Tummers, L., & Noordegraaf, M. (2020). Working on working together: A systematic review on how healthcare professionals contribute to interprofessional collaboration. Journal of Interprofessional Care, 34(3), 1–11. https://doi.org/10.1080/13561820.2019.1636007

Zorek, J. A., Lacy, J., Gaspard, C., Najjar, G., Eickhoff, J., & Ragucci, K. R. (2021). Leveraging the interprofessional education collaborative (IPEC) competency framework to transform health professions education. American Journal of Pharmaceutical Education, 85(7), 8602. https://doi.org/10.5688/ajpe8602

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