Preliminary Care Coordination Paper

Preliminary Care Coordination Paper

Preliminary Care Coordination Paper

Health Problem and Best Practices for Improvement Example

In-patient management and care in rehabilitation facilities have for long been significantly affected by the incidence of pressure ulcers. The National Pressure Advisory Panel (NPUAP) indicates that the distribution of pressure ulcers is as follows; hospitals (38%), nursing homes (24%), and 24% in home care agencies (Boyko, Longaker & Yang, 2018 Preliminary Care Coordination Paper). Pressure ulcers occur in long-term bedridden patients and have been shown to worsen their outcome in terms of morbidity and mortality (Zaidi & Sharma, 2020). First, the condition causes pain and discomfort to the patients hence reducing their quality of life. It is also disproportionately burdensome for the elderly patients who tend to have comorbidities hence further complicating the course of their treatment and outcomes (Boyko et al., 2018). Pressure ulcers especially in grades 2 and above are open wounds that generally predispose those patients to hospital-acquired infections (HAIs), which are difficult to treat and also complicate recovery.

Preliminary Care Coordination Paper

Financial and psychological effects also arise from pressure ulcers. The condition prolongs hospital stay either directly or indirectly when HAIs develop. Zaidi & Sharma (2020 Preliminary Care Coordination Paper) intimate that the cost of treating decubitus ulcer patients averages 2.5times more than treating patients without them. It is these spiraling healthcare costs, extended hospital stay, and the general physical discomfort that occasion the development of psychological distress in the patients (Schiffman, 2017). Collectively, the complications deprive the patient’s quality of life and also impact their family and support systems. Interventions for the health issue thus span preventive practices, early recognition, and prompt care.

Decubitus ulcer risk factors and causation include prolonged immobilization, advanced age, diabetes mellitus, peripheral vascular disease (PVD), nutritional deficits, and nursing factors. Post-surgical patients, patients with fractures, ICU patients, or those with severe motor deficits are of the highest risk (Kopuz & Karaca, 2017 Preliminary Care Coordination Paper). However, in the spectrum of care, the risk can be reduced by instituting specific nursing interventions. These include 2-hourly turning or use of pressure pads and ripple mattresses to reduce effective pressure at the bony prominences as well as bladder and bowel care to minimize skin moisture which increases incidences of ulcers (Boyko et al., 2018). Patient education on the same is important to enhance understanding and adherence.

In those who develop the condition, regular wound cleaning and dressing, analgesia, antibiotic cover, and appropriate nutritional supplementation are key (Schiffman, 2017). In the latter, a diet rich in vitamin C, and iron aid in wound healing. Further, for the specific predisposing comorbidities, controlling the underlying conditions is vital; diabetes and PVD have to be managed through sugar control and appropriate lifestyle modifications, and neurologic patients may also benefit from physiotherapy (Zaidi & Sharma, 2020). Control of, and management of pressure ulcers is thus a multidisciplinary endeavor, bringing aboard the nurses, nutritionists, physicians, physiotherapists, and psychologists.

Established Goals to Address the Pressure Ulcers Problem

Use Guides to Prevent Pressure Ulcers

            Prevention of pressure ulcers from happening is the best bet against managing the nagging healthcare issue. It is thus paramount that all hospitals and nursing facilities be furnished with prevention guides that provide the general outlook of averting the problem. Specific facilities can then modify the guide to suit their patient population. The Braden Scale is effective in risk stratifying patients for pressure ulcers (Shiffman, 2017 Preliminary Care Coordination Paper). It employs an assessment of the individual risk of patients developing pressure ulcers using six parameters checked within 6 hours of admission. The parameters include sensory perception, moisture, activity, mobility, nutrition as well as friction and shear, each graded in 0-4, with total scores of more than 16 indicating greater risk (Shiffman, 2017). Therefore, the scale is easy to implement, reproducible, and evidence-based hence can be adopted by such facilities to assess the development of pressure ulcers.

Simplified Pressure-Ulcer Management Algorithms

Management needs simplification in the event prevention fails and bedsores develop. Evidence-based measures can be simplified into an algorithm that aids in the management of the condition. Shiffman (2017), while citing Padula et al. notes that a process flow chart used to demonstrate the steps in pressure ulcer care is then availed to nurses in the facilities and nursing homes. Uniformity of care and results is aided by the institution of specific inputs, outputs, implementation procedures, and monitoring parameters. Inputs then include prevention procedures such as nutritional optimization, ambulation, skincare, and regular turning or wound care, antibiotics, and analgesics in established ulcers. Implementation mechanisms involve demonstrations of application as well as relevant consultations (Shiffman, 2017 Preliminary Care Coordination Paper). Expected outcomes are then outlined as ulcer-free patients.

Active Ulcer Monitoring Mechanisms

Aside from managing the condition, active monitoring is essential in ensuring recovery is attained and that recurrences are avoided. The Pressure Ulcer Scale for Healing (PUSH) can be employed to assess information on wound exudate, size, and tissue type, to show whether the ulcer is healing (Zeigler et al., 2016 Preliminary Care Coordination Paper). Also, to effect patient-centered management, patient-specific risk factors can be analyzed using a Pareto chart to enhance the efficacy of interventions instituted. Accordingly, the caregivers have to be trained on the use of and reading the charts and guides to promote a reduction in the burden of bedsores and enhance recovery.

Community Resources for Effective Care Continuum

Varied community resources exist for the advancement of knowledge regarding the prevention and managing of pressure ulcers. The ‘Advancing Excellence in America’s Nursing Homes Campaign’ refers to a campaign towards the improvement of life and care quality in nursing homes to reduce pressure ulcers (Nazarko, 2018 Preliminary Care Coordination Paper). The ‘California Quality Improvement Organization’ also works with nursing homes to help in reducing pressure ulcers. Finally, ‘Hartford Institute for Geriatric Nursing’ also provides vast information relating to pressure ulcers hence is important in educating both the public and the caregivers.

Preliminary Care Coordination Paper References

NURS-FPX4050 Assessment 1 Instructions: Preliminary Care Coordination Plan

  • PRINT

This is the first part of the assessment——-

  • Develop a 3 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care. Preliminary Care Coordination Paper

The first step in any effective project is planning. This assignment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a particular health care problem.

Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.

Demonstration of Proficiency

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.
    • Analyze a health concern and the associated best practices for health improvement.
  • Competency 2: Collaborate with patients and family to achieve desired outcomes.
    • Describe specific goals that should be established to address a selected health care problem.
  • Competency 3: Create a satisfying patient experience.
    • Identify available community resources for a safe and effective continuum of care.
  • Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care. Preliminary Care Coordination Paper
    • Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
    • Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

Preparation for Preliminary Care Coordination Paper

Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.

To prepare for this assessment, you may wish to:

  • Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.

Instructions for Preliminary Care Coordination Paper

Develop the Preliminary Care Coordination Plan

Complete the following:

  • Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. Possible health concerns may include, but are not limited to:
    • Heart disease (high blood pressure, stroke, or heart failure).
    • Home safety.
    • Pulmonary disease (COPD or fibrotic lung disease).
    • Orthopedic concerns (hip replacement or knee replacement).
    • Cognitive impairment (Alzheimer’s disease or dementia).
    • Pain management.
    • Mental health.
  • Identify available community resources for a safe and effective continuum of care.
Document Format and Length
  • Your preliminary plan should be an APA scholarly paper, 3 pages in length.
    • Remember to use active voice, this means being direct and writing concisely; as opposed to passive voice, which means writing with a tendency to wordiness.
  • In your paper include possible community resources that can be used.
  • Be sure to review the scoring guide to make sure all criteria are addressed in your paper.
    • Study the subtle differences between basic, proficient, and distinguished. Preliminary Care Coordination Paper
Supporting Evidence

Cite at least three credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.

Grading Requirements

The requirements, outlined below, correspond to the grading criteria in the Preliminary 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.

  • Analyze your selected health concern and the associated best practices for health improvement.
    • Cite supporting evidence for best practices.
    • Consider underlying assumptions and points of uncertainty in your analysis.
  • Describe specific goals that should be established to address the health care problem.
  • Identify available community resources for a safe and effective continuum of care.
  • Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
  • Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.
    • Write with a specific purpose with your patient in mind.
    • Adhere to scholarly and disciplinary writing standards and current APA formatting requirements. Preliminary Care Coordination Paper
Additional Requirements

Before submitting your assessment, proofread your preliminary care coordination plan and community resources list to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Be sure to submit both documents.

2nd part of the assignment ————————————————————————————————————————————————————————————————————————————————————————————————–

For this assessment, you will evaluate the preliminary care coordination plan you developed in the first part of the assignment using best practices found in the literature.

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. Preliminary Care Coordination Paper

Demonstration of Proficiency

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. Preliminary Care Coordination Paper
  • 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.

Preparation

In this assessment, you will evaluate the preliminary care coordination plan you developed in the first part of the assignment 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.

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

Instructions

  • Build on the preliminary plan, developed in the first part of the assigment, to complete a comprehensive care coordination plan. Preliminary Care Coordination Paper
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 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 four 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. Preliminary Care Coordination Paper

  • 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. Preliminary Care Coordination Paper
    • 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. Preliminary Care Coordination Paper
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.