Assessment 4: Final Care Coordination Plan

In the US, family and domestic violence is a common problem that affects around 10 million people a year. Research suggests that domestic violence involves a significant proportion of the population, with approximately one in four women and one in nine men experiencing such violence (Grillo et al., 2019). Healthcare practitioners often encounter patients who have suffered from family or domestic abuse. Abuse of any kind, including financial, physical, sexual, mental, and psychological, may be classified as domestic or family violence and can affect people of all ages, including adults, children, and the elderly. Domestic violence hurts one’s physical and mental health, as well as productivity, quality of life, and, in some cases, fatality. This paper aims to outline the key priorities for a care coordinator when discussing a plan to address domestic violence with a patient and their family members.

Patient-Centered Health Interventions

The Healthy People 2030 initiative, which addresses domestic violence, aims to lower various forms of violence, including physical assaults, sexual assaults, and gun-related injuries (Rauhaus et al., 2020). When the victim is afraid, it may be difficult to identify domestic violence, especially when they go to the ER or a doctor’s office. Creating an evaluation process and being aware of the possible connection between domestic and family abuse and the symptoms and indications that the patient is presenting with is essential. More than 80% of victims of family and domestic abuse go to hospitals for treatment; other victims may see therapists, dentists, and other medical professionals (Grillo et al., 2019). Patient-centered care for these individuals primarily focuses on assessing and managing physical injuries, pain, and psychological trauma.

All healthcare practitioners, such as nurses, physicians, doctor’s assistants, dental practitioners, nurse practitioners, and pharmacists, should conduct routine screening. Interdisciplinary screening coordination is crucial for safeguarding victims and reducing adverse health outcomes within 24 hours (Lutgendorf, 2019). Proving the correlation between injuries and domestic abuse poses a significant challenge. The primary focus is on injuries that significantly risk one’s life or physical well-being. Following stabilization and physical assessment, laboratory tests and imaging modalities such as X-rays, CT scans, or MRI scans may be necessary. Healthcare professionals should prioritize addressing the root cause of the patient’s condition upon their arrival at the emergency department.

After confirming the patient’s stability and absence of pain, it is essential to conduct a comprehensive assessment of individuals who have disclosed experiencing abuse. The primary focus is on evaluating safety. Utilizing a set of predetermined questions can assist in reducing ambiguity during the patient’s assessment. In imminent peril, it is advisable to promptly seek assistance from an advocate, a shelter, a victim hotline, or legal authorities within 24 hours (Lutgendorf, 2019). In the absence of imminent peril, the evaluation should prioritize the examination of mental and physical well-being while also ascertaining the presence of any prior or ongoing instances of abuse. The responses determine the suitable intervention.

Survivors of intimate partner violence demonstrate elevated rates and severity of depression, with symptoms potentially enduring for up to five years following the cessation of violence (Grillo et al., 2019). Survivors of intimate partner violence (IPV) also experience higher rates of anxiety, posttraumatic stress disorder (PTSD), and issues related to alcohol and substance abuse. In an ideal world, the hospital would allow patients to speak privately with a medical professional, be prepared to handle emergencies, offer consolation measures like information, support, and emotional support, and be able to connect patients with local social service organizations. The Institute of Medicine (IOM) and the U.S. Preventive Services Task Force recommend IPV screening and counseling for all adolescent and adult women as part of preventive care. The Department of Health and Human Services has also adopted these recommendations as part of the preventive care provided through the Affordable Care Act.

Evaluation of the Patient:

Let’s quickly assess our client and her needs before we present our care coordination strategy. Our client is Ms. D. Smith, a 26-year-old woman with cerebral palsy who also needs a trachea due to her condition. Her mother, Ms. V. Wyatt, lives with them and takes care of her. Following a relapse of her Lupus diagnosis, Ms. Wyatt is now improving in her health. As a result, she needed additional help from family members and home health nurses to provide Ms. Smith with care until she can once again operate independently. Ms. Smith has not been given the necessary treatment throughout this time, which has led to episodes of tracheal decannulation, skin breakdown, and two recent falls from her bed and wheelchair (Adams et al., 2019).

Health-Related Issues That May Be Included:

Case management has requested the assistance of trusted family members and homecare specialists in order to create an effective treatment plan for Ms. Smith. It was determined that (a) the care of her trachea, (b) the instruction of her staff to prevent falls, and (c) the maintenance of the integrity of her skin were areas of concern for her health and safety. It has been agreed that Ms. Smith’s care will undergo another evaluation on October 15, 2019, to see whether any changes to her current course of treatment are necessary to ensure her continuing health and security. This choice was made as a result of the choice to conduct the evaluation, which has been made. It will be crucial for Ms. Wyatt to perform one of the two tasks flawlessly. 1. Verify that Ms. Smith has enough family support to ensure her ongoing safety and care until Ms. Wyatt has healed fully (Radder et al., 2020).

It appears that Ms. Wyatt will be able to recover to the point where she can resume her duties as Ms. Smith’s full-time carer. If neither of these two possibilities becomes available within the next month and a half, Ms. Smith will be transferred to a facility that provides temporary relief for a shorter period of time. Because she won’t be able to have a home of her own for some time, she will have to remain in foster care for the foreseeable future. Homecare services will be offered inside the home on a round-the-clock basis, seven days a week, in order to assist with care and to educate family members who are prepared to take on the obligations of caregiving. As a direct result of this, Ms. Wyatt will take part in both physical treatment and occupational therapy in an effort to speed up her own rehabilitation. In addition to this, she will participate in training to improve the ways in which care is provided to patients in light of the difficulties in healthcare that were discussed before (Radder et al., 2019).

Ethics-related factors to take into account:

Notwithstanding the fact that we are approaching Ms. Smith’s needs from the perspective of client-centered care, we still have a duty to consider ethical nursing care obligations. It is our responsibility as a nurse to ensure that the patient receives the care that is in their best interests. To guarantee that Ms. Smith continues to have the same level of physical and mental wellness that she has had her whole life—that is, staying at home with her family—we adhere to industry standards and act in her best interests. She will maintain the same degree of physical and mental health that she has in the future thanks to this. Not only are we being held accountable for our own behavior, but also that of the carer who assisted our consumer (s). Last but not least, it is our responsibility to do business in a way that does not in any way, shape, or form harm our customers, whether or not such harm was intended.

The Patient’s health problems include:

The patient was found to have the chronic obstructive pulmonary disorder (COPD), a type of lung disease that causes the airways to get blocked as a result of smoking. The illness is accompanied by a multitude of symptoms, the most common of which are coughing up mucus and wheezing. Those who have been diagnosed with COPD have a significantly increased chance of contracting a number of other illnesses, including coronary heart disease, lung cancer, and a wide range of other ailments. Because of this, it is crucial to managing the situation appropriately. The patient struggles to effectively use the necessary self-management abilities during this period (Cartier et al., 2020). The patient, for instance, is not as well-informed as they ought to be on the significance of taking all recommended medications, like ciprofloxacin and prednisolone, exactly as instructed. Less instruction is also given to the patient on how to control the various chest compressions required for reoxygenating the lungs, as well as how to handle the dry coughing that occurs during the procedure. Second, the patient is less informed about the techniques that can be used to enhance breathing based on their current condition. This is problematic because the patient’s general health depends on breathing improvement. The patient finds this difficult because one of their main worries is improving their breathing. Last but not least, the patient is not immune to influenza, which is known to exacerbate the symptoms of COPD. The vaccination has not been received by the patient. The likelihood of the existing condition getting worse has not been decreased as a result of the person’s failure to receive the immunization, which is cause for concern (Bahr & Weiss, 2019).

About the Coordination of Care’s Priorities

The following is a list of the priorities that should be taken into account while planning care coordination. In order to gain a deeper grasp of the patient’s viewpoints, values, and desires, the nurse and doctor must stay in constant communication with one another as well as with the patient and the patient’s family. Critical stages in the procedure include assessment and ongoing patient and family education about the course of the disease. After it is accomplished, it might be possible to implement coordinating services and a number of other disciplines. Even after being discharged from hospitals or other care facilities, such as nursing homes or rehabilitation facilities, where they had been residing, patients continue to receive medical treatment. In order to enhance the patient’s outcomes, it is vitally important to keep evaluating the patient. This can be done through follow-ups and the use of the appropriate therapies to achieve patient-specific objectives. There is a demand that access is granted to Jane Doe’s home. The healthcare team’s role is to figure out how she can get the proper diet, exercise, transportation, medications, and resources, as well as how to manage her weight. Coupled with having the means to support one’s own lifestyle and medical care,

References

Adams, S., Stinson, J., Moore, C., Beatty, M., Desai, A., Radmand, A., … & Orkin, J. (2019). 16 Assessing the requirements for a patient-facing virtual platform to enhance care coordination for children with medical complexity. Paediatrics & Child Health, 24(Supplement_2), e7-e7.

Bahr, S. J., & Weiss, M. E. (2019). Clarifying model for continuity of care: A concept analysis. International journal of nursing practice, 25(2), e12704.

Cartier, Y., Fichtenberg, C., & Gottlieb, L. M. (2020). Implementing Community Resource Referral Technology: Facilitators And Barriers Described By Early Adopters: A review of new technology platforms to facilitate referrals from health care organizations to social service organizations. Health Affairs, 39(4), 662-669.

Radder, D. L., Nonnekes, J., Van Nimwegen, M., Eggers, C., Abbruzzese, G., Alves, G., … & Bloem, B. R. (2020). Recommendations for the organization of multidisciplinary clinical care teams in Parkinson’s disease. Journal of Parkinson’s disease, 10(3), 1087-1098.

Assessment 4: Final Care Coordination Plan

You did a very nice job evaluating the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature and then expanding it here in the final paper. You described the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You identified changes to the plan based upon EBP and discuss how the plan includes elements of Healthy People 2030. Overall, this is a very good effort on this final care coordination plan addressing the health care problem of CP; and I value your time and professionalism and creativity in preparing this. I made a few recommendations on how some criteria might achieve a higher performance score. I hope you will take the information you learned on creating this final care coordination plan back to your facility to identify opportunities to improve health outcomes. This would be a great way to share nursing knowledge.  I look forward to seeing what you do in your future educational endeavors. Great work getting through the final assessment of this course!

For this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

Introduction

NOTE: You are required to complete this assessment after Assessment 1 is successfully completed.

Care coordination is the process of providing a smooth and seamless transition of care as part of the health continuum. Nurses must be aware of community resources, ethical considerations, policy issues, cultural norms, safety, and the physiological needs of patients. Nurses play a key role in providing the necessary knowledge and communication to ensure seamless transitions of care. They draw upon evidence-based practices to promote health and disease prevention to create a safe environment conducive to improving and maintaining the health of individuals, families, or aggregates within a community. When provided with a plan and the resources to achieve and maintain optimal health, patients benefit from a safe environment conducive to healing and a better quality of life.

This assessment provides an opportunity to research the literature and apply evidence to support what communication, teaching, and learning best practices are needed for a hypothetical patient with a selected health care problem.

You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment.

Preparation

In this assessment, you will evaluate the preliminary care coordination plan you developed in Assessment 1 using best practices found in the literature.

To prepare for your assessment, you will research the literature on your selected health care problem. You will describe the priorities that a care coordinator would establish when discussing the plan with a patient and family members. You will identify changes to the plan based upon EBP and discuss how the plan includes elements of Healthy People 2030.

Instructions

Note: You are required to complete Assessment 1 before this assessment.

For this assessment:

• Build on the preliminary plan, developed in Assessment 1, to complete a comprehensive care coordination plan.

Document Format and Length

Build on the preliminary plan document you created in Assessment 1. Your final plan should be a scholarly APA-formatted paper, 5–7 pages in length, not including title page and reference list.

Supporting Evidence

Support your care coordination plan with peer-reviewed articles, course study resources, and Healthy People 2030 resources. Cite at least three credible sources.

Grading Requirements

The requirements, outlined below, correspond to the grading criteria in the Final Care Coordination Plan Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

• Design patient-centered health interventions and timelines for a selected health care problem.
  • Address three health care issues.
  • Design an intervention for each health issue.
  • Identify three community resources for each health intervention.
• Consider ethical decisions in designing patient-centered health interventions.
  • Consider the practical effects of specific decisions.
  • Include the ethical questions that generate uncertainty about the decisions you have made.
• Identify relevant health policy implications for the coordination and continuum of care.
  • Cite specific health policy provisions.
• Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.
  • Clearly explain the need for changes to the plan.
• Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.
  • Use the literature on evaluation as guide to compare learning session content with best practices.
  • Align teaching sessions to the Healthy People 2030 document.
• Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
• Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Additional Requirements

Before submitting your assessment, proofread your final care coordination plan to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan.

Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

• Competency 1: Adapt care based on patient-centered and person-focused factors.
  • Design patient-centered health interventions and timelines for a selected health care problem.
• Competency 2: Collaborate with patients and family to achieve desired outcomes.
  • Describe priorities that a care coordinator would establish when discussing the plan with a patient and family member, making changes based upon evidence-based practice.
• Competency 3: Create a satisfying patient experience.
  • Use the literature on evaluation as a guide to compare learning session content with best practices, including how to align teaching sessions to the Healthy People 2030 document.
• Competency 4: Defend decisions based on the code of ethics for nursing.
  • Consider ethical decisions in designing patient-centered health interventions.
• Competency 5: Explain how health care policies affect patient-centered care.
  • Identify relevant health policy implications for the coordination and continuum of care.
• Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
  • Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
  • Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.