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Disseminating the Evidence Scholarly Video Media Submission
Chronic illnesses such as diabetes pose significant problems in medical practice mainly concerning the elderly since they are recurrent, long-term, and require strict management. The main care coordination is crucial in increasing patient outcomes and lowering the complication rates concerning diabetes (American Diabetes Association, 2019). With a focus on a systematic and comprehensive evaluation, NURS FPX 6614 Assessment 3 healthcare professionals can improve the degree of control of diabetic complications, prevent hospitalizations, and improve the quality of life among elderly patients with diabetes.
PICOT Question and Introduction of Issues
The PICOT Question
In elderly patients with chronic conditions like diabetes (P), how does implementing a comprehensive care coordination program (I) compared to the current fragmented care approach (C) affect the management of chronic diseases and quality of life (O) over 12 months (T)?
Introduction of Issues
The chronic conditions of elderly patients who are diabetic include fragmented care that is characterized by poorly co-coordinated services, inconsistent management, and lack of continuity in communications among the various caregivers. Prolonged fragmentation of care might decrease the effective management of chronic diseases, raise hospitalization rates, and compromise the quality of life (Yen-Yi Juo et al., 2019). NURS FPX 6614 Assessment 3 Care of diabetes in older people entails a multifaceted model of handling the disease since there is a need to coordinate many health services and address the needs of the patients completely. Fragmented care not only deducts the health outcomes of patients with chronic diseases but also worsens the quality of health, disparities, and cost of care (Joo, 2023). Thus, the problem could be solved by implementing the idea of a coordinated care model to increase the quality of delivering care, as well as to improve the health of elderly patients with chronic diseases.
NURS FPX 6614 Assessment 3 Analysis of Care Coordination Efforts
To deal with the issues of care and diagnosis fragmentation in elderly individuals suffering from diabetes mellitus, there were several important developments in care coordination. A most important aspect of integrated care management is that all the patient’s care is coordinated through a single point where primary care providers, specialists, and care managers are involved (Karam et al., 2021). EHRs make it easier to share information through coordination tools, and they give care teams a way to manage a patient’s health information effectively. Telehealth services include remote appointments, thus cutting out the necessity of several physical visits and letting monitor the patient’s state and make necessary changes to the treatment plan at once.
Key Implications
The attempts to initiate care coordination essentially have far-reaching consequences. Integrated care services, electronic care records, and telehealth are ways that aid the coordination of chronic diseases in elderly diabetes patients by increasing the stability of their care plan. This system should also be able to address the multifaceted nature of health and it implies improved disease control. Also, better care management leads to lower hospitalization incidences due to the provision of proper timely attention to such conditions that would otherwise require hospitalization (Sarkies et al., 2020). However, NURS FPX 6614 Assessment 3 synchronized approaches benefit elderly patients’ quality of life through the clear organization of the involved services, thus reducing the difficulties linked to different types of healthcare services.
Practice Related to Services and Resources
The new practice has brought some improvements in the sector by developing the Comprehensive Care Management Program when handling elder patients with chronic diseases like diabetes. This program comprises ordinary check-ups, prescriptions of medicines, and the development of individualized care plans thus catering to the challenges that come along with the management of chronic diseases (Foo et al., 2021). Apart from these services, other advancements have been made in the technological aspect for the efficient running of health systems which include implementation of EHRs and telehealth systems. Electronic Health Records (EHRs) allow health practitioners to easily provide an account of a patient’s health by receiving, processing, and distributing patient information to all other health practitioners who are involved in the patient’s treatment (Hernandez & Gonzales, 2021).
Click on the for getting: NURS FPX 6614 Assessment 1: Defining a Gap in Practice
Telehealth platforms offer an opportunity for regular remote check-up visits so that a patient’s treatment plan can be supervised and adjusted from time to time without scheduling regular face-to-face sessions. These changes are to enhance the coordination of care functions and fill a gap pointed out in systems of care fragmentation. These changes solve the related problem of silos, which cause diseconomy in care coordination and patient status variability. NURS FPX 6614 Assessment 3 Coordination of care and the employment of such elements as EHRs and telehealth should produce more sustained and preventive healthcare (Zhang & Saltman, 2021). The studies and existing literature reveal that integrated care models enhance health status and decrease admission rates.
Key Care Coordination Effort
One integral part of this approach entails the formation of a transdisciplinary care team comprising the patient’s primary care physicians, specialists, and care managers. This team successfully employs EHR for the exchange of detailed patient information and telehealth applications for receiving patient information consonant with continual care (Bell et al., 2020). Through the combination of these resources, there are ample ways to address the NURS FPX 6614 Assessment 3 multiple aspects of managing chronic conditions, hence the enhancement of care, quality, consistency, and the improvement of the patient’s condition. Coordinated care as an approach brings together individuals who can work in a team and hence the high level of organization in addressing complications arising from chronic diseases addresses the objective of improving patient care.
Efforts to Build Stakeholder Engagement within the Interprofessional Team
The strategies of the leading practitioner change in practice comprised of role definition of all workers, communication, and the adoption of technologies. Educational sessions on the EHRs and telehealth platforms were discussed and scheduled. They are critical in the promotion of care coordination and patient outcomes (Shoemaker et al., 2021). To enhance collaboration and ensure that all staff members were committed to the new changes, standard meetings were scheduled to enhance multidisciplinary team discussion on patients’ care, issues, and developments.
NURS FPX 6614 Assessment 3 Strengthening Stakeholder Relations
Strengthening stakeholder relations was complex and it entailed activities such as the assignment of roles, communication, and authority, sharing of information, and training and information sharing. Mapping out activities in an explicit manner was necessary when it came to the roles of distinct team members to improve collaboration and one’s sense of responsibility regarding care plans, thus strengthening groups’ performance and cooperation (Yousefian et al., 2021). To this end, daily huddle meetings and staff feedback sessions were conducted to deal with emerging issues and to disseminate information. Consequently, members of the project are encouraged to share their opinions, contribute a lot of information, and get the latest updates on the patients’ condition (Courbier et al., 2019). Moreover, systematic adherence and informative educational activities were organized to train all team members on EHRs and telehealth applications; as a result, the staff was made with adequate competency and awareness for deploying these technologies for patient care.
Addressing Uncertainties
Some measures were taken to address the uncertainties. One particular feedback management system was adopted since the team members’ feedback was instrumental in decision-making and corrections where necessary. This made it possible to get feedback and experience the reaction of the targeted audience in real-time, looking for possible problems and addressing them as soon as possible if necessary (Courbier et al., 2019). NURS FPX 6614 Assessment 3 periodic review of the care plan and its revision was done to minimize any arising complications and keep it as relevant as possible to deal with the different complications that may occur and provide the best care to the patient.
Recommended Next Steps
To get the same result in the future, it is suggested to conduct the training repeatedly and keep a follow-up. Future education about EHRs and telehealth for all individuals on the team will guarantee that all team members can use them efficiently to provide optimal care coordination. This means that such a monitoring system can enable timely changes when issues are noticed regarding the improved outcomes of patients or the performance of the team of practice (Thomas et al., 2021). In this regard, the further effective and efficient application of technology must remain one of the key approaches to appropriate resource management. NURS FPX 6614 Assessment 3 Organizations must use and integrate EHRs and telehealth services so that there is no duplication of services and the efficiency of care delivery is boosted.
Moreover, the concept of promulgating a secure context includes developing proper guidelines for the protection of the patient’s rights, safety, and confidentiality during the usage of new technologies (Galvin & DeMuro, 2020). It also has a framework for reviewing the care coordination mechanism with paper and electronic components depending on the patient’s satisfaction and technology evolution to promote rational use of resources with patient safety as a priority. Such an approach promotes a long-lasting and safer environment in care coordination by embracing the aspect of quality improvement due to the dynamic perception of patients’ needs.
Conclusion
Concluding the care coordination process, integrated care models expand the opportunity for patients to improve results due to the focus on the diverse aspects of chronic disease management. NURS FPX 6614 Assessment 3 intervention showed that the key to change lay in the integration of the varied professions and the strategies for technology adoption. Major areas of learning are the triangular relationship between the sender, receiver, and benefit delivered and the importance of sustained efforts and constant review of care processes to ensure that optimal patient’ benefit is realized. It also creates the path for patient care physicians to provide the elderly with attentiveness and quality care irrespective of their chronic conditions like diabetes.
References
American Diabetes Association. (2019). Clinical Diabetes, 37(1), 11–34. https://doi.org/10.2337/cd18-0105
Bell, S. K., Delbanco, T., Elmore, J. G., Fitzgerald, P. S., Fossa, A., Harcourt, K., Leveille, S. G., Payne, T. H., Stametz, R. A., Walker, J., & DesRoches, C. M. (2020). JAMA Network Open, 3(6). https://doi.org/10.1001/jamanetworkopen.2020.5867
Courbier, S., Dimond, R., & Bros-Facer, V. (2019). Foo, C. D., Surendran, S., Jimenez, G., Ansah, J. P., Matchar, D. B., & Koh, G. C. H. (2021). Primary care networks and Starfield’s 4Cs: A case for enhanced chronic disease Management. International Journal of Environmental Research and Public Health, 18(6), 2926. https://doi.org/10.3390/ijerph18062926
Galvin, H. K., & DeMuro, P. R. (2020). Developments in privacy and data ownership in mobile health technologies, 2016-2019. Yearbook of Medical Informatics, 29(1), 32–43. https://doi.org/10.1055/s-0040-1701987
Hernandez, M., & Gonzales, I. (2021). Academic Journal of Science and Technology, 4(1), 1−9–1−9. https://academicpinnacle.com/index.php/ajst/article/view/86
Joo, J. Y. (2023). Nursing Open, 10(6). https://doi.org/10.1002/nop2.1607
Nursing care coordination for patients with complex needs in primary healthcare: A scoping review. International Journal of Integrated Care, 21(1), 16. https://doi.org/10.5334/ijic.5518
Sarkies, M., Long, J. C., Pomare, C., Wu, W., Clay-Williams, R., Nguyen, H. M., Francis-Auton, E., Westbrook, J., Levesque, J.-F., Watson, D. E., & Braithwaite, J. (2020). Avoiding unnecessary hospitalisation for patients with chronic conditions: A systematic review of implementation determinants for hospital avoidance programmes. Implementation Science, 15(1). https://doi.org/10.1186/s13012-020-01049-0