1 Comprehensive Needs Assessment L

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Comprehensive Needs Assessment
Learner’s Name
Capella University
NURS-FPX6610: Introduction to Care Coordination
Instructor Name
August 1, 2019
Copyright ©2019 Capella University. Copy and distribution of
this document are prohibited.

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Comprehensive Needs Assessment
A comprehensive health needs assessment of patients enables
health care providers to
systematically use their resources to disperse care efficiently. In
this paper, a comprehensive
needs assessment of a simulated patient is discussed to highlight
the importance of
comprehensive needs assessments in identifying and reducing
gaps in patient care and

implementing effective care coordination. This paper discusses
the various dimensions of a
patient’s needs and the strategies to extract relevant patient
information to understand these
needs to establish the significance of a health needs assessment.
This paper also presents
effective evidence-based practices in care coordination and the
importance of a multidisciplinary
approach to patient care for improving health care outcomes.
Current Gaps in Mr. Decker’s Care
Mr. Decker is a 79-year-old diabetic patient readmitted to one
of Vila Health’s hospitals.
Initially admitted with a badly infected toe, Mr. Decker’s
inability to adhere to medical
instructions after discharge has resulted in him being readmitted
with sepsis. Mr. Decker’s
readmission can be attributed to the following gaps in care:
• Lack of an interdisciplinary approach to care: The inability of
the health care provider to
ensure that factors such as diabetes and aging are given due
consideration while dispersing
care
• Failure to ensure adequate post-discharge support: Lack of

adequate efforts from the care
provider to ensure that the patient effectively carries out the
post-discharge care instructions
• Lack of consideration for the patient’s financial standing: The
patient’s poor financial
standing was not considered during the design and management
of the patient’s care

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To ensure that Mr. Decker’s physiological, social, religious, and
psychological needs are
effectively addressed, the needs assessment tool adopted is the
Patient Centered Assessment
Method. The method is an integrated needs assessment tool that
assesses patients’ physical,
social, psychological, and mental well-being needs. The tool
was selected because it is action
oriented. It facilitates the addressal of patients’ holistic needs,
expanding beyond the realm of
physiological health care to address their psychosocial needs
(Maxwell et al., 2018).
Informational Needs for Patient’s Optimal Care:
An effective assessment of Mr. Decker’s current care needs
depends on the following
types of information:
• Mr. Decker’s clinical information, namely age, allergies,
weight, current diagnosis, and
medical history (Kelley et al., 2013)

• Personal information such as his schedules, preferences,
typical behaviors, and interests,
which will provide clarity on how Mr. Decker’s care needs are
to be addressed (Kelley et al.,
2013)
Strategy for Gathering Additional Necessary Assessment Data
As a personal interview does not help gather all the information
necessary for the
adequate delivery of care, the following data collection
strategies are formulated:
• Thoroughly scanning Mr. Decker’s activities across social
media platforms to collect
information about his behavior patterns, his daily routines, and
the significant events he has
been a part of will help provide clarity on his personalized
needs and the various interrelated
factors affecting his care.
• In-depth interviews with close relatives and friends about Mr.
Decker’s habits, nature, and
recent activities will help understand the factors that affect care
and facilitate personalized
care measures that suit his situation.

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• The electronic health record systems at Mr. Decker’s
preceding health care providers are
important sources of clinical information. Health information
exchange systems are set up to
access Mr. Decker’s longitudinal clinical data from different
health care providers to get
clarity on the various factors such as diabetes and aging that

have a bearing on his current
condition. The clinical history will help ensure that Mr.
Decker’s care addresses these
interrelated factors and facilitates a holistic treatment.
Societal, Economic, and Interdisciplinary Factors Affecting
Patient Care
The factors affecting Mr. Decker’s health care outcomes are the
following:
• Aging: The physiological changes that occur in an aging
person present immense challenges
in the diagnosis, treatment, and recovery of geriatric patients
(above 60 years of age) with
sepsis. Geriatric patients usually show atypical, non-specific
symptoms such as altered
mental status, lethargy, dehydration, loss of appetite, and
weakness, making the diagnosis
challenging. Being an inflammatory consequence to an
infection, sepsis is conventionally
diagnosed using systemic inflammatory response syndrome
criteria, which are not normally
met by geriatric patients. According to Clifford et al. (2016),
geriatric patients undergo
pharmacokinetic changes, namely degeneration in the ability to
absorb, metabolize,

distribute, and eliminate drugs. These pharmacokinetic changes
have significant implications
on the treatment of sepsis and, consequently, result in the need
for special considerations
while treating geriatric patients. Also, geriatric adults usually
witness immunosenescence
(changes in the immune system), which impedes the swiftness
of the recovery process
in geriatric patients (Clifford et al., 2016).
• Financing for health care: Mr. Decker is a 79-year-old man
whose accessibility to health care
depends primarily on Medicare, the national insurance health
care program. Although
Medicare covers hospitalization and medical insurance, the
level of care depends on the type

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of insurance plan opted. The 2019 cost estimates for Medicare
stand at 437 U.S. dollars as
the premium per month for the hospital insurance plan (Part A)
and 135.50 U.S. dollars as
the premium per month for the medical insurance plan (Part B),
with higher costs for other
high-end plans (U.S. Centers for Medicare and Medicaid
Services, n.d.). Mr. Decker’s dismal
income status has affected the nature of the Medicare plan he
could afford, thus impacting
care outcomes.

• Social support: Mr. Decker has limited social support in the
form of an aged wife who lives
with him, a daughter who visits them occasionally, and his
nephew and nephew’s wife, who
offer occasional assistance. This limited social support has had
a significant bearing on his
ability to carry out the care instructions laid out by the care
providers. Many studies provide
evidence about the impact of social support on health outcomes.
In a study by Schöllgen et
al. (2011), the participants interviewed reported that increased
social support was associated
with functional and subjective improvements in health (as cited
in Rapoza et al., 2016). A
study conducted by White et al. (2009) found that geriatric
adults with insufficient social
support reported poorer health outcomes than geriatric adults
who were satisfied with their
present social support (as cited in Rapoza et al., 2016). The
inadequacy of social support in
Mr. Decker’s case has been the basis for the worsening of his
health condition from a simple
toe wound to sepsis.
• Diabetes: The fact that Mr. Decker is also diabetic has

impacted his care by making him
vulnerable to contracting infections at a higher rate and facing
increased chances of
prolonged mortality as a result of sepsis. This can be
substantiated by the fact that diabetes
causes a decline in the functioning of a patient’s immune cells,
diminishing the ability to
clear bacterial formations and increasing infection
complications (Frydrych et al., 2017).

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Relating Patient Care and Care Coordination Outcomes to
Professional Standards
The outcomes of patient care and care coordination can be
accounted for by measuring
the patient safety and quality outcomes of patient care and care
coordination. Patient safety
outcomes for specific patient care coordination are measured
against the standards laid out in the
National Quality Forum’s safety report for 2017 and The Joint
Commission’s National Patient
Safety Goals for 2019. The rationale for measuring safety
outcomes based on the National
Quality Forum’s safety report is the comprehensiveness of the
report and the credibility of the
forum, whose primary focus is the development of safety
measures (National Quality Forum,
n.d.). The rationale for selecting The Joint Commission’s
National Patient Safety Goals as a

standard for patient safety is that the goals are developed based
on the suggestions of a highly
interdisciplinary advisory group and the analysis of national
sentinel event data (Armstrong,
2014). The quality outcomes of care coordination will be
measured using the Care Coordination
and Transition Management Logic Model for registered nurses
as the standard (Haas & Swan,
2014a). The rationale is that the logic model not only lays out
care coordination quality outcomes
but also offers holistic linkages between nurse competencies,
care coordination, and outcomes
(Haas & Swan, 2014b). Also, the logic model offers an
innovative approach for interprofessional
teams focusing on patient-centered care (Haas & Swan, 2014a).
The Joint Commission annually releases patient safety goals,
which have been deemed
nationally as qualitative standards for patient safety. Some
significant standards for patient safety
are identification of a patient by both name and date of birth,
dispersal of the right test results to
the right patient, accurate labeling of medicines, medical device
alarms going off in real time,

and ensuring infection prevention, which will set the right
benchmark for ensuring effective
patient safety outcomes (The Joint Commission, 2019). In terms
of The Joint Commission’s
standards for patient safety, the care to Mr. Decker was
characterized by 100% infection

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prevention during acute care, accurate administration of
medicines with no adverse effect on the
body, and a successful operation without any complication.
Some important care coordination
quality outcomes defined by the Care Coordination and
Transition Management Logic Model are
the needs assessment’s taking into account patient needs,
preferences, and goals; transmission of
the patient’s care plan with zero errors; constant updating of
care coordination plans; evidence-
based practices’ achieving treatment outcomes of 80%; and
optimal understanding of the
interdisciplinary roles between team members (Haas & Swan,
2014b). On this front, the specific
patient care coordination witnessed 70% treatment outcomes,
the patient’s care plan was able to
accommodate 90% of the patient’s needs and preferences, and
the care plan was updated in a
timely manner with zero issues reported within the cross
disciplinary team.
Evidence-Based Practices for Successful Implementation of

Patient Care Coordination
The following evidence-based practices have been identified to
be effective in
implementing successful care coordination for patients with
sepsis:
• GENeralized Early Sepsis Intervention Strategies (GENESIS)
is an initiative launched for
the continuous improvement of the quality of care for patients
with sepsis. GENESIS is a
comprehensive program with highly pertinent treatment
measures such as implementing
institutional assessments for the prevalence of sepsis and
mortality, identifying sepsis emergencies,
executing 6-hour sepsis bundle interventions via highly
coordinated sepsis teams, and implementing
feedback. In their study on the impact of GENESIS on a
treatment group of 4,801 patients, Cannon
et al. (2012) found an average in-hospital mortality reduction of
14% and a reduction in the duration
of stay of 5.1 days in comparison to patient groups that did not
receive treatment under GENESIS
(as cited in Perez, 2015).
• Another effective practice can be the adoption of a centrally
coordinated, multifaceted

quality improvement program implemented by many hospitals in
Brazil (Noritomi et al.,
8
2014). Noritomi et al. (2014), in their study of 10 private

hospitals implementing the
program, found the initiative to include two phases. The first
phase comprised establishing a
local committee, setting up a screening procedure for the early
detection of sepsis, carrying
out proven treatments, establishing guidelines for empirical-
based antimicrobial therapy,
formulating specific routines for swift laboratory sampling, and
establishing routines to
enable the efficient administration of antibiotics. The second
phase included the collection
of data and creation of reports on the rate of compliance and
mortality in line with the
benchmarks set by the hospital. This practice is a promising one
to adopt as Noritomi et al.
(2014) found that the studied hospitals showed a decrease in
mortality rates from 55%
before the implementation of program to 26% after the
implementation of the program.
Best Practices from the Perspective of Population Health on
Patient Outcomes
From the population standpoint of improving the health
outcomes of geriatric patients
with sepsis, the following care practices are found to be

credible and effective:
• As geriatric patients show atypical, nonspecific symptoms
(Clifford et al., 2016), a study by
Singer et al. (2016) found the sequential organ failure
assessment score a valuable tool in
determining signs of organ disfunction and mortality and, thus,
helpful in the diagnosis of
sepsis. Singer et al. (2016) found that the sequential organ
failure assessment score has
widespread familiarity in the clinical care community and
serves as an acceptable marker for
mortality risks.
• The Surviving Sepsis Campaign guidelines, which are widely
accepted, formulate the Sepsis
Six bundle as a best practice for the treatment of sepsis (Lat et
al., 2018). Hancock (2015)
describes the Sepsis Six bundle as an early intervention program
that calls for each patient to
receive three diagnostic and three therapeutic steps to treatment
within the hour of
recognition of the health condition (as cited in Lat et al., 2018).

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Benefits of Multidisciplinary Approach to Patient Care
Mr. Decker is an old patient with multiple diagnoses and several
complex and multiple
needs. A multidisciplinary approach to health care through
effective consultation and
collaboration involving Mr. Decker, family support, and
interdisciplinary teams serves as the

only approach that can address the complex multi morbidity,
social issues, and psychological
issues faced by him (Department of Health & Human Services,
n.d.). This multidisciplinary
approach to patient care can also reduce the gaps due to
societal, economic, and interprofessional
factors. The approach is built on egalitarian-based collaboration
between interdisciplinary teams
that helps break the hierarchy existing in traditional health care
organizations and, thus, improves
the satisfaction of employees in the workplace (Hughes, 2018).
The adoption of a multidisciplinary approach to patient care
ensures improved patient
outcomes. In their study on improving operating room
efficiency, Oyderk et al. (1988) found
that the adoption of multidisciplinary operating room teams
improved turnover time by 16
minutes and considerably decreased delays when compared with
operating room teams that are
not multidisciplinary, resulting in reduced hospitalization costs
(as cited in Epstein, 2014). This
study supports the argument that a multidisciplinary approach to
patient care helps reduce the
duration of stay, reduce hospitalization costs, and improve

patient satisfaction.
Conclusion
A comprehensive needs assessment of patient care is presented
in this paper through the
case of Mr. Decker. This paper successfully identifies the
various interrelated factors, such as
aging, diabetes, social support, and financial conditions, that
need to be addressed for a patient to
achieve optimal care. The studies presented in the paper have
identified credible standards for
the specific care coordination outcomes to draw measures from.
This paper successfully
identifies holistic and judicious evidence-based practices for
managing sepsis. Finally, a strong
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case for a multidisciplinary approach to care coordination is
presented with empirical evidence.

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2019.pdf
2019.pdf
glance
glanceComprehensive Needs AssessmentLearner’s NameCapella
UniversityNURS-FPX6610: Introduction to Care
CoordinationInstructor NameAugust 1, 2019Current Gaps in Mr.
Decker’s CareInformational Needs for Patient’s Optimal
Care:Strategy for Gathering Additional Necessary Assessment
DataSocietal, Economic, and Interdisciplinary Factors Affecting
Patient CareRelating Patient Care and Care Coordination
Outcomes to Professional StandardsEvidence-Based Practices
for Successful Implementation of Patient Care CoordinationBest
Practices from the Perspective of Population Health on Patient
OutcomesBenefits of Multidisciplinary Approach to Patient
CareConclusion
Our brain needs to quickly solve problems and make decisions.
These processes can become difficult, or time consuming, when
our brain receives conflicting information, and our attention can
become taxed. An example that demonstrates what can occur
when our brain is confronted with conflicting information is the
Stroop Effect. Take time to try this experiment:

Can you say the color of each word instead of reading it? Can
you say the color of each word instead of reading it?
Instructions: Say aloud the color ink that you see, not the
printed word:
· Understanding Problem-Solving and Decision-Making Skills
Web Page
· Books and Resources for this Week
· Berman, M. G., Kross, E., Krpan, K. M., Askren, M. K.,
Burson, A., Deldin, P. J., . . . Jonides, J. (2012). Interacting
with nature improves ...
Link
· Fougnie, D., & Morois, R. (2011). What limits working
memory capacity? Evidence for modality-specific sources to the
simultaneous storage of ...
Link
· Greiff, S., Holt, D. V., & Funke, J, (2013). Perspectives on
problem solving in cognitive research and educational
assessment: analytical, ...
Link
· Pezzutia, L., Artisticob, D., Chirumboloc, A., Piconea, L., &
Dowdb, D, (2014). The relevance of logical thinking and
cognitive style to everyday ...
Link

· Roets, A., & Van Hiel, A. (2011). An integrative process
approach on judgment and decision making: The impact of
arousal, affect, motivation, and ...
Link
· Complete the Quiz for Weeks 6 and 7
Quiz
Web Page
Link
Link
Link

Link
Link
Quiz
This can be difficult to do, as a processing delay in cognition
occurs because of competing or incompatible functions in the
brain – and your brain must solve the problem of what function
to attend to first. Be sure to review the following site for more
information on the Stroop
Effect: http://www.snre.umich.edu/eplab/demos/st0/s troopdesc.
html
Web Page
Link

Link
Link
Link
Link
Quiz
1
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improve the quality of a paper by helping both the reader and
the author, as will soon be discussed. Comment by Author:
In POETS, this is the O for organization. See Writing Center:
Organization.
Level 2 Section Heading Is Aligned Left, Bold, and Title Case
The heading style recommended by APA consists of five levels
(APA, 2020b, pp. 47–48). This document contains multiple
levels to demonstrate how headings are structured according to
APA style. Immediately before the previous paragraph, a Level
1 section heading was used. That section heading describes how
a Level 1 heading should be written, which is centered, bold,
and using uppercase and lowercase letters (also referred to as
title case). For another example, see the section heading
“Writing an Effective Introduction” on page 3 of this document.
The heading is centered and bold and uses uppercase and
lowercase letters. If used properly, section headings can
significantly contribute to the quality of a paper by helping the
reader, who wants to understand the information in the
document, and the author, who desires to effectively describe
it.Section Heading Purposes Comment by Author: This is a
Level 3 heading. Notice it is aligned left, bold, italic, and title
case. The paragraph begins on a new line. See Academic Writer:
Heading Levels.
Section Headings Help the Reader. Section headings serve
multiple purposes, including helping the reader understand what
is being addressed in each section, maintain an interest in the
paper, and choose what they want to read. For example, if the
reader of this document wants to learn more about writing an
effective introduction, the previous section heading clearly
states that is where information can be found. When subtopics
are needed to explain concepts in greater detail, different levels
of headings are used according to APA style. Comment by
Author: This is a Level 4 heading—it is indented, bold, and title

case. The heading ends in a period, and the text begins on the
same line as the heading.
Section Headings Help the Author. Section headings not only
help the reader; they also help the author organize the document
during the writing process. Section headings can be used to
arrange topics in a logical order, and they can help an author
manage the length of the paper. In addition to an effective
introduction and the use of section headings, each paragraph of
an academic paper can be written in a manner that helps the
reader stay engaged. Comment by Author: Level 4 heading
Section Headings Can Demonstrate Fine Detail. Short papers
and assignments may not require or need a Level 5 heading, but
these will be indented, bold, italic, and title case and end with a
period. Note the text starts on the line at the end of the heading
following the period. Comment by Author: Level 5
headingHow to Write Effective Paragraphs Comment by
Author: The Writing at Capella multimedia presentation will
help you understand the POETS model.
Capella University’s Writing Center (n.d.) has adopted a new
set of writing standards to assist learners in their goals to
improve their scholarly writing. It is based on five skills known
by the mnemonic POETS. In other words, a well-developed
Capella paper will demonstrate the following standards. The
paper will have a clear purpose statement, be logically
organized, utilize current and appropriate evidence that is
properly cited, maintain a scholarly tone, and demonstrate
proper grammar and writing mechanics in the sentence structure
(Capella Writing Center, n.d.). Academic writing is sometimes
considered dry and boring. A learning experience may need that
formula to encourage learning in different ways as the learner
moves from passive learner to active scholar. This growth,
according to Gilmore et al. (2019), requires the writer to not
only think but also to write differently. Comment by Author:
Notice the et al. here—this article has four authors. In APA
seventh style, any source with three or more authors will use et
al. for every citation, eliminating the need to remember when

this appropriate. For more information, see Academic Writer:
Citing References in Text.Bias-Free Language
In the seventh edition of the APA manual, another focus is on
eliminating bias in language in order to provide a more
inclusive tone in scholarly writing. While long considered a
grammar issue, it is acceptable in APA to utilize they as a
singular pronoun (APA, 2020b). In fact, there is an entire
chapter of the manual dedicated to ways to reduce bias in
scholarly writing. It is important to use an appropriate level of
specificity in descriptions and use sensitivity with the use of
labels. Other sections include guidelines on age, disability,
gender, race and ethnicity, sexual orientation, socioeconomic
status, and participation in research. Be aware of
intersectionality, a term used to describe a person based on their
identified multiple identities, interconnectivity, social context,
power relations, complexity, social justice, and inequalities that
can result in oppression (Cole, 2019; Hopkins, 2017).
Comment by Author: See Academic Writer:
Intersectionality for the guidelines. Comment by Author: Note
the two citations—in a single set of parentheses and separated
by a semicolon. The citations are listed
alphabetically.Considering Direct Quotations
Another important point to consider is the use of direct
quotations in papers. While plagiarism is considered an
academic integrity issue, many learners are concerned with
issues such as self-plagiarism and unintentional plagiarism, and
there are others who may go as far as purchasing papers for
submission (Colella & Alahmadi, 2019). As a learner travels
along their chosen academic pathway, their writing skills and
mechanics are expected to improve. It is imperative that the
learner transition from finding information and quoting the
author word for word to using the information to support an
idea, paraphrase, and then synthesize and express the findings
in one’s own words. Having said that, there are situations in
which quotations may be appropriate, so it is important to cite
them properly. According to the seventh edition of the APA

manual, “When quoting directly, always provide the author,
year, and page number of the quotation in the in-text citation in
either parenthetical or narrative format” (APA, 2020b, p. 270).
If there are not page numbers, identify the location in another
manner (such as a paragraph number). Comment by Author:
Notice the quotation marks around the quoted text and the
placement of the punctuation after the parenthetical citation.
See Academic Writer: Quotation Marks for more on the use of
quotation marks.
Notice that the above quote contains fewer than 40 words. There
is a different style for quotes containing 40 words or more.
These longer quotes use a block quotation format:
Do not use quotation marks to enclose a block quotation. Start a
block quotation on a new line and indent the whole block 0.5 in.
from the left margin. If there are additional paragraphs within
the quotation, indent the first line of each subsequent paragraph
an additional 0.5 in. Double-space the entire block quotation; do
not add extra space before or after it. Either (a) cite the source
in parentheses after the quotation’s final punctuation or (b) cite
the author and year in the narrative before the quotation and
place only the page number in parentheses after the quotation’s
final punctuation. Do not add a period after the closing
parenthesis in either case. (APA, 2020b, p. 272) Comment by
Author: Notice there is no period after this citation in a block
quote—it looks odd, but it is APA style. See Academic Writer:
Quotation Marks. Conclusion
A summary and conclusion section, which can also be the
discussion section of an APA style paper, is the final
opportunity for the author to make a lasting impression on the
reader. The author can begin by restating opinions or positions
and summarizing the most important points that have been
presented in the paper. For example, this paper was written to
demonstrate to readers how to effectively use APA style when
writing academic papers. Various components of an APA style
paper that were discussed or displayed in the form of examples
include a title page, introduction section, levels of section

headings and their use, the POETS format, bias-free language,
in-text citations, a conclusion, and the reference list.
References Comment by Author: Remember all headings are
bold.
American Psychological Association. (2020a). Ethical
principles of psychologists and code of conduct (2002, amended
effective June 1, 2010, and January 1, 2017).
https://doi.org.apa.org/ethics/code/index.aspx
American Psychological Association. (2020b). Publication
manual of the American Psychological Association (7th ed.).
Comment by Author: This is something new in APA
seventh style—you no longer need the location of the publisher
for print books. Also note that if the author is the publisher, it
is only listed as the author. This guideline is found on page 324
of the APA manual.
Capella University. (n.d.). Writing Center.
https://campus.capella.edu/writing-center/home
Cole, N. L. (2019, October 13). Definition of intersectionality:
On the intersecting nature of privileges and oppression.
ThoughtCo. https://www.thoughtco.com/intersectionality-
definition-3026353
Colella, J., & Alahmadi, H. (2019). Combating plagiarism from
a transformation viewpoint. Journal of Transformative Learning,
6(1), 59–67. https://jotl.uco.edu/index.php/jotl/article/view/184
Gilmore, S., Harding, N., Helin, J., & Pullen, A. (2019).
Writing differently. Management Learning, 50(1), 3–10.
https://doi.org/10.1177/1350507618811027
Hopkins, P. (2017). Social geography I: Intersectionality.
Progress in Human Geography, 43(5), 937–947.
https://doi.org/10.1177/0309132517743677
Appendix Comment by Author: See Academic Writer:
Publication Manual § 2.14 for more on appendices.Tips for the
Reference List
· Always begin a reference list on a new page. It should be
placed before any appendices, figures, or tables and titled
References.

· Set a hanging indent that starts with the second line and is
double-spaced. You can look in the Paragraph menu of
Microsoft Word for formatting the hanging indent so that you
will not have to tab the indent. It gives the text a smoother look
that remains consistent, even if you make edits.
· The reference list is in alphabetical order by the first author’s
last name. A reference list only contains sources that are cited
in the body of the paper, and all sources cited in the body of the
paper must be included in the reference list. If you did not cite
it, do not list it.
· The reference list above contains an example of how to cite a
source when two documents are written in the same year by the
same author.
· The lowercase letters are used after the date to differentiate
the sources. The “a” reflects the alphabetical order i n the
reference list—not whether it appeared first in the text.
· The year is also displayed using this method for the
corresponding in-text citations, as in the following sentence:
The author of the first citation (American Psychological
Association, 2020b) is also the publisher; therefore, the word
Author is no longer used in the seventh edition.
· DOI is the digital object identifier.
· It can be found on the first page of an article, on the copyright
page of a book, in the database record of a work, or by
searching Crossref.
· Even if the book is in print, if there is a DOI, use it.
· Always use the hyperlink format for a DOI—it will always
start with https://doi.org/ and will be followed by a number. If
the DOI is not in this format, convert it. Do not alter this
format, and do not add a final period.
· There is a short DOI service at http://shortdoi.org/.
· URL is the uniform resource locator.
· If there is no DOI, the URL should be used in the reference.
· Copy and paste the URL directly into your list.
· Do not add a period at the end.
· Do use “Retrieved from” before a URL.

· The Colella and Alahmadi reference is an example of how to
cite a source using a URL. Please note that you will not use the
Capella link that is often provided in the courseroom. If the
URL contains a database title, such as EBSCO or ProQuest, or
the name Capella, do not use that in your citation as it will only
work for Capella learners and faculty.
· For examples and further information on references go to:
· Academic Writer: Sample References.
· Academic Writer: Reference List.
Complete an interactive simulation of the role of the nurse in
health care coordination. Then, create a comprehensive patient
needs assessment of 4-5 pages based on that simulation.
Introduction
Note: Each assessment in this course builds on your work from
preceding assessments; therefore, complete the assessments in
the order in which they are presented.
Care coordination is an emerging and complex field in the
health care system because of the growing number of providers,
the various settings of care, and the numerous methods of
delivering care. Hospitals are implementing several
interventions to address gaps in care coordination, such as
enhanced systems of communication, information technology,
and personnel resourcing. This assessment provides an
opportunity for you to complete a comprehensive needs
assessment.
In the 2000 report To Err Is Human: Building a Safer Health
System, the Institute of Medicine identified collaborative
communication and the reduction of medical errors as top
priorities to improve the quality and safety of patient care. In
response to this, the National Quality Forum (NQF), a nonprofit
organization that works to catalyze improvements in health
care, identified care coordination as an important national
strategy to improve patient safety and quality of care delivery.
Coordination of care supports patient safety and quality and is a
recognized professional standard shared by registered nurses

regardless of their practice settings. Whether educating a patient
about his or her medication and plan of care or reviewing
follow-up care, nurses are essential in facilitating the continuity
of care for all patients. Historically, nurses have engaged in
coordinating care for every one of their patients. As the
landscape of health care evolves, so does care coordination.
Reference
Institute of Medicine. (2000). To err is human: Building a safer
health system. National Academies Press.
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.
· What are the key reasons for completing a patient needs
assessment?
· Which types of information are likely to be most valuable for
improving patient outcomes?
· What are the benefits of a multidisciplinary approach to
coordinated care?
To prepare for this assessment, complete the following
simulation:
· Vila Health: The Nurse's Role in Care Coordination.
This simulation explores the roles that case managers and other
team members play in care coordination. Upon completion of
the exercise, you should have a better understanding of care
coordination trends and their historical contexts. Use the
information available in this simulation to begin your
assessment of the patient, Mr. Decker.
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.
Example Assessment: You may use the following to give you an
idea of what a Proficient or higher rating on the scoring guide
would look like:
· Assessment 1 Example [PDF].
Requirements
Complete a comprehensive needs assessment for Mr. Decker,
based on the information provided in the Vila Health simulation
and your own research.
Comprehensive Needs Assessment Format and Length
Format your comprehensive needs assessment using APA style:
· Use the APA Style Paper Tutorial [DOCX] provided. Be sure
to include:
. A title page and references page. An abstract is not required.
. A running head on all pages.
. Appropriate section headings.
· Your needs assessment should be 4–5 pages in length, not
including the title page and references page.
Supporting Evidence
Cite 3–5 sources of scholarly or professional evidence to
support your assessment.
Conducting the Assessment
The requirements outlined below correspond to the grading
criteria in the scoring guide. Be sure that your needs assessment
addresses each point, at a minimum. Read the Comprehensive
Needs Assessment Scoring Guide to better understand how each
criterion will be assessed.
· Identify current gaps in a patient's care.
. Use an appropriate needs assessment tool to identify gaps.
This tool may be one in use at your place of employment, one
you locate for yourself, or one provided by faculty.
. Consider the types of patient information that will be most
useful in assessing the current level of care.

· Develop a strategy for gathering additional necessary
assessment data not readily available from an initial patient
interview.
. Consider the full range of interrelated needs that affect the
patient’s health.
· Discuss 3–5 societal, economic, and interprofessional factors
most likely to affect patient outcomes.
. Consider the potential effects of these factors on outcomes.
. Support your conclusions with evidence.
· Relate specific patient and care coordination outcome
measures to professional standards.
. Provide the rationale for measuring outcomes based on
established agencies and organizations.
. Describe the relationship between specific outcomes and the
identified standards.
· Identify evidence-based practices for successful
implementation of care coordination.
. Use relevant and credible sources from the research literature.
. Consider best practices for a population-health focus on
patient outcomes.
· Advocate for the benefits of a multidisciplinary approach to
patient care.
. Provide the key points in your argument.
. Support your assertions with evidence.
· 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 more difficult to focus on the substance of
your needs assessment.
· 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 comprehensive
needs assessment 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.
. Identify current gaps in a patient's care.
. Develop a strategy for gathering additional necessary
assessment data not readily available from an initial patient
interview.
· Competency 2: Explain the effect of societal, economic, and
interprofessional factors on patient outcomes and the care
coordinator's role.
. Discuss societal, economic, and interprofessional factors most
likely to affect patient outcomes.
. Advocate for the benefits of a multidisciplinary approach to
patient care.
· Competency 3: Evaluate care coordination plans and outcomes
according to performance measures and professional standards.
. Relate specific patient and care coordination outcome
measures to professional standards.
· Competency 4: Develop collaborative interventions that
address the needs of diverse populations and varied settings.
. Identify evidence-based practices for successful
implementation of care coordination.
· 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.
This is the transcript for the Vila Health: The Nurse's Role in
Care Coordination. You can get information here.

Introduction
Care coordination is one of the fastest growing and evolving
trends in the nursing field. In order to be an effective care
coordinator, it is important to understand the roles that case
managers and other care coordination team members play in a
health care setting. It is also valuable to understand how these
roles have evolved—and continue to evolve— over time. In this
activity, you will learn more about the role of care coordination
in an acute care setting.
After completing the activity, you will be prepared to:
· Summarize the roles that case managers and other team
members play in care coordination.
· Contextualize care coordination and today's care coordination
trends historically.
Details
Congratulations! You have been just hired as a case
management intern in the Care Coordination Department at St.
Anthony Medical Center. Located in Minneapolis, St. Anthony
is a 120-bed hospital in the Vila Health system, which operates
facilities in several Midwest states. The Care Coordination
Department manages patient cases throughout the entire
hospital.
Since it's your first day, your first task is to get oriented. Your
preceptor will help you get started. To learn more about the
roles that care coordinators play in nursing, you'll be talking
with experienced case managers, social workers, and other
members of the team. You'll also sit in on a coordination
planning meeting.
Office
It looks like you have an email from Denise McGladrey, your
new preceptor. Click the icon to read it.
From: Denise McGladrey
Subject: Your first day

Welcome to St. Anthony! We're so glad to have you on the Care
Coordination team. As you know, I am going to be your
preceptor. My job is to help you transition into your new role as
case management intern and to offer you support. You should
feel free to come to me with questions.
I have several meetings today, so I won't be able to meet with
you until this afternoon. In the meantime, since this is your first
day, I want you to learn more about your role by talking with
some of the people with whom you'll be collaborating. I'd like
for you to ask them questions about the case management role
and the skills you'll need to be successful. Most of the people
you'll be talking to have a good deal of experience, so I'd a lso
like for you to ask questions about how the field has evolved
over the years.
I've gone ahead and scheduled two interviews with you: one
with Vicki Vasquez, who, as you know, is the Director of Case
Management here at SAMC. The other interview will be with
Samantha Rockwell, an experienced social worker who you'll be
coordinating with quite a bit in the near future. You'll also have
the opportunity to schedule interviews with your choice of a
number of other team members.
I'll be catching up with you later. Have a great day!
—Denise
Schedule Interviews
It looks like you need to speak with Mackenzie, Crystal, and
Joyce about this incident—and then find some strategies for
motivating them to succeed. You should go talk with each of
them now.
Seth Patterson
Case Manager
Can you please describe your role in the department?
Seth: I coordinate care for all kinds of people in the hospital.
They tend to give me cases involving older adults, since that's
my background, but for the most part all the case managers need
to be equipped to work with all kinds of cases. I worked with

geriatric patients almost exclusively with another hospital.
Other case managers come to me sometimes when they need
geriatric resources or have questions about how to help elderly
patients.
In your opinion, what are some of the most important things a
new case manager needs to know?
Seth: Here's a tip: make yourself a master list of phone
numbers! I can help you get started with that. After a while, you
figure out who to call at each insurance company when you
really need to get something done, or who to call at various
social service agencies to get accurate information about
resources, and so forth. I can't even tell you how much time my
list saves me!
What are some of the biggest mistakes case managers make?
Seth: One of the biggest problems case managers have is with
coordinating transfers from one facility to another—especially
when you're talking about older adults, because moving them
can be very risky. When patients go to the wrong facilities, that
can be traumatic for the patient and costly for the hospital. It's
important to do your research and find the best possible
facilities for patients so they don't have to be moved again. That
can be a real challenge because of insurance issues… ugh! It's
incredibly frustrating when the best facility for someone isn't
covered by insurance. But that's just part of our jobs….
negotiating stuff like that with insurance companies on behalf
of our patients' best interests. It's also really important to figure
out whether sending somebody home is a good idea. Sometimes
home health care is the best solution, but sometimes it's not,
depending on the family situation and all kinds of factors you
need to consider.
In your experience, how has care coordination changed?
Seth: Dealing with insurance companies and Medicare and
federal regulations and all of that… it just gets more
complicated all the time. I like to think that I'm an advocate for
our patients, helping them navigate through all this red tape and
regulation. If it's this hard for me to navigate things, I can only

imagine how hard it is for the patients—especially if they're
elderly or have language barriers and stuff like that.
What are the some of the most important trends in care
coordination?
Seth: Electronic medical records are revolutionizing what we
do. And overall this is a good thing. I mean, a big part of what
we do is to try to prevent fragmentation of care, and EMRs
make a world of difference with that. On the other hand, as
someone who's worked with elderly people, I know what a
problem EMRs can pose to patients who aren't technologically
literate. I've heard and seen horror stories. One of the nurses at
a clinic where I used to work, she told me about this elderly
woman who had elevated blood sugar levels. Her manager
wouldn't let her call the woman to get a retest because the clinic
wanted to push people into using the new patient portal. You
know, because of meaningful use issues? If enough people
didn't use the portal, the clinic could lose funding. Well, this
woman was in her 80s, and lo and behold, she never looked at
her electronic record and wound up at the hospital with a blood
sugar level over 600!
Nora Jackson-Green
Case Manager
Can you please describe your role in the departme nt?
Nora: Oh boy, where do I even get started? I don't want to
sound melodramatic, but sometimes I feel like I'm a human life
raft. The medical system is this massive sea of confusing
information. And sometimes there's dangerous sea monsters who
are more interested in getting paid than helping a patient get to
land. My job is to navigate the patients through all this choppy
water so they don't drown.
Nora: Case managers need to know how to communicate with
the patients and their families! They need to make sure that
families truly have the resources they need to help care for a
patient. It's not enough to ask patients what they need, because

a lot of times they don't know what they need. Or they totally
underestimate how much physical and emotional work goes into
caring for a loved one. It's our job to anticipate their needs
before a crisis happens. And as Baby Boomers like me get
older, it's going to be more and more important to know how to
help families navigate these kinds of situations. We're not a
society that's set up to help people who are old and sick! So it's
up to us to make sure people get what they need.
Nora: Case managers really need to be on the lookout for red
flags that something's wrong, or that something's not going to
go smoothly. Because otherwise, patients who really need our
help can fall through the cracks. We don't always have a lot of
time with the patients, so we need to pay attention to all kinds
of details. If a patient is showing any possible signs of
dementia, for example, that's a red flag. We need to investigate
further. If a patient is taking a potentially dangerous drug, or if
they show signs of prescription drug dependency, we need to
follow up and not just send that patient home. It's kind of like
being a detective, only you don't know exactly what you're
looking for.
Nora: Well, I think the whole health care system has changed in
that there's so much more emphasis on accountability. We have
to prove we're doing a good job. Care coordination has evolved
with the emphasis on outcomes and quality. It used to be that
care coordination was a more unofficial part of what nurses did.
Now, it's being recognized more and more as a critical job duty,
and that's because coordinated care leads to better outcomes.
coordination?
Nora: Like I said, the emphasis on outcomes and quality has
really changed care coordination. We're constantly being
evaluated on patient outcomes. There are direct financial
consequences for the hospital if our outcomes aren't good. That
means that care coordination is taken more seriously, because it

absolutely has to be.
Vicki Vasquez
Director of Case Management
Vicki: Well, the part of my job that I like the most is serving as
a role model and mentor to the team members in this
department. I've worked in care coordination for a long time. So
if someone feels like they're up against a brick wall and can't
figure out how to help a patient, I can put on my coach hat. I
enjoy that. A more challenging part of my job is working with
the bureaucracy to make sure that patients get what they need
and that the hospital gets paid. Health care law and regulations
change all the time. You'll be shocked at how much they
change. As the leader of this department I have to make sure I'm
100% on top of these changes—especially since St. Anthony is
an Accountable Care Organization. The hospital is constantly
evaluated on 33 quality indicators, and our ability to manage
complicated cases is essential if we're going to keep our rank
up.
Vicki: There's a lot you need to know to be an effective case
manager. One of the most crucial skills is problem solving. If
you're looking for a job where there are clear-cut answers in a
guidebook, well, maybe you should be an accountant or
something. Every case is like a puzzle that needs a unique
solution, and a lot of times, even the best solutions need
troubleshooting.
And a big part of learning how to solve these problems is
looking at patients holistically. You know what I mean by
holistically, right? That means you have to look at the whole
situation and understand how all the parts of the situation fit
together. You have to look at the whole picture—health history,
psychological factors, family situation, financial situation,
ethnic and religious factors. There are all kinds of barriers to
care you can miss if you don't look at how the factors fit

together.
Vicki: I think different case managers tend to make different
mistakes. Like I said, it's really important to understand patients
holistically. When case managers focus exclusively on medical
issues to the exclusion of a patient's family or social situation,
that's a big miss. And another serious error that case managers
can make is exceeding their scope of practice. It's very
important not to overstep boundaries and make decisions that
belong to physicians or other members of the team. And that's
an easy trap to fall into… like, for example, it can be very
tempting to make a decision about changing a patient's
medication or dosage without consulting the primary physician.
Maybe the physician is hard to reach that day, and maybe it
seems very obvious to the case manager that a medication needs
to be discontinued. But those kinds of decisions can lead to
critical errors and liability issues. Case managers absolutely
need to respect the primary physician's role as the team lead.
And sometimes, like it or not, they need to follow orders.
Vicki: We're starting to understand care coordination as a
specialized job duty in a way that we didn't before. There's
always been care coordination. Nurses did that as a part of their
jobs, and they still do. But now we have full time case
managers, and schools are offering coursework and formal
training in care coordination.
coordination?
Vicki: Well, the health care system as a whole has gone through
some major paradigm shifts. From the perspective of our work, I
think the most important trend has to do with value-based
payments. The hospital's ability to receive reimbursement is
directly tied to quality and patient outcomes—especially since
we're an Accountable Care Organization. Because of this, care
coordination professionals play a crucial role in overseeing care
to prevent errors. And overall, this is a positive change that

improves patient care. But it does add a new level of pressure
on case managers.
Samantha Rockwell
Social Worker
Samantha: I consult with case managers to make sure that
they're considering all the social issues that impact a patient's
ability to get the care they need and to manage their care. I meet
with patients and find out what's going on in their lives… their
financial situations, their family situations, possible barriers to
care, anything really that might impact their ability to get care.
I also work with case managers to help locate appropriate
resources for clients
Samantha: Case managers need to remember that care
coordination is a transdisciplinary field. You have to be able to
collaborate effectively with an interdisciplinary team. In fact, I
would say that collaboration is possibly the most important skill
that a case manager needs. You work with all kinds of people
both inside and outside the hospital, and with insurance
companies and families too. Nobody expects case managers to
have all the answers, but they need to know who to work with
and how to work with people to get these answers.
Samantha: When case managers overlook barriers to care, that's
a big problem. Sometimes case managers have blind spots when
it comes to identifying these barriers. A few years ago, I worked
with a case manager that just didn't seem to understand
transportation barriers. She would set up follow up care for
patients way out in the suburbs. But a lot of our patients, they
rely on public transit and can't get out that far. Or they're old
and they don't drive, or they don't feel comfortable driving on
freeways to new places. I don't know why it never occurred to
her that this could be a problem.

Samantha: There's a lot more awareness of the importance of
looking at patients' needs as they relate to sociological issues.
This kind of awareness has been around informally for a long
time—I mean, nurses have always been aware of these kinds of
issues, and social workers have been employed by hospitals for
a long time. But now social workers are being brought in more
routinely to assess situations, as opposed to bringing us in later
after something goes wrong. There are a lot of opportunities for
social workers to go into care coordination right now, and that's
exciting.
coordination?
Samantha: Thanks to the Affordable Care Act, most people have
access to medical care now. We used to see a lot of uninsured
patients in the hospital, and now uninsured patients are the
exception. This is a good change, of course—a very good
change. But it also brings challenges. We're working with
people now who have little or no experience with the health
care system. They need to be educated on how to work
effectively with us. A lot of people don't realize how things like
deductibles work, and that health insurance doesn't cover every
single expense. And the Affordable Care Act also has led to
more people in the system from lower socioeconomic groups.
These people tend to have more barriers to care. We have to
anticipate that some people will need more guidance through the
system than others.
Lucas Branch
Diabetes Educator
Lucas: I work with case managers to make sure that patients get
the information they need about diabetes care and prevention.
When appropriate, I provide patients with resources to help
them manage their diabetes. Often I help patients who are
diagnosed with a chronic condition and who also have diabetes,
since that new condition might mean they have to make changes
in their diabetes management plan. I also talk with patients who

have prediabetes or risk factors.
Lucas: From my perspective, case managers need to be aware
that it's critical to provide patients with accurate information—
and explain to them how to use it. With diabetes, there's so
much misinformation out there. Some patients underestimate the
danger of diabetes and think it's no big deal. Others are
completely terrified and think it's a death sentence, and they
don't realize they have the power to manage it. And that's true
of other medical conditions as well. People rely way too much
on Dr. Internet to get the information they need. A case
manager needs to make sure that patients have real information
they can use.
Lucas: As a team, it's so important to do everything we can to
prevent fragmentation of care. Fragmentation brings costs up
and quality down, and it can be really dangerous. We need to
make sure patients aren't getting conflicting information or
medication from different providers.
Lucas: That's a better question for someone like Nora, who's
been working in this field for so much longer than me! But even
in the short time I've been here, I can see how much more care
goes into managing patient transfers. We do a lot more
investigating now to make sure patients are going to the right
facilities.
coordination?
Lucas: The team mentality has made a really big difference. The
idea that you bring in a diabetes educator, you bring in a
dietician, you coordinate with a social worker…. that kind of
interdisciplinary thinking leads to much better outcomes.
Karen Wu
Dietician

Karen: I work with patients to make sure they have the
information they need about nutrition in relation to their
conditions. I educate, and give suggestions. A lot of patients
have no idea what a difference changes in their diet and
exercise can make. People often feel really overwhelmed by the
prospect of changing their diet and health habits, so I help them
come up with realistic strategies for making changes.
Karen: I think case managers need to manage how
overwhelming it can be for patients to be in the hospital .
Someone gets diagnosed with a chronic or a terminal illness,
and then they suddenly get all this information about all this
stuff they need to do—medication, physical therapy, doctor's
appointments, changes in diet and exercise, so much! Case
managers should help make the process feel more manageable
for the patient, not less.
Karen: Not following up with patients. I mean, we don't have
unlimited time, so we can't be checking up on people
constantly. But we need to do things like schedule follow-up
phone calls. I can't tell you how many times a case manager has
called and there was a mix-up of some kind.
Karen: The fact that a dietician is brought in on such a regular
basis is a big change! The role of nutrition used to be glossed
over. Or doctors and nurses would tell people to make changes
in their diet without giving them enough information about how
to make realistic changes. These days, we work together as a
team to identify all the things we can help the patient do to
achieve a better outcome.
coordination?
Karen: I think there's more awareness to barriers to care. That's
definitely true for nutrition. There are very real barriers that
make it hard for people to get nutritious food, like food deserts.

For people who rely on food shelves, it can be very difficult to
meet special dietary needs. And culture and ethnicity can play a
huge role too. Some traditional ethnic food is actually a lot
healthier than the typical American diet, but that's not always
the case. Care coordination teams are getting better at
identifying these kinds of barriers and identifying solutions.
Office
It looks like you have another email from Denise McGladrey,
your new preceptor.
Patient Meeting Email
Email
From: Denise McGladrey
Subject: Patient meeting
I see you've been busy meeting with team members to learn
more about care coordination roles and trends. Thank you so
much for doing that!
I have another task for you that will help you get oriented.
There's going to be a meeting this afternoon to discuss care
coordination strategies for a patient. Here's the background: a
79-year-old man named Fred Decker was seen here two weeks
ago with a badly infected toe. After the infection cleared up, he
was sent home with instructions. Unfortunately, he and his
family weren't able to follow the instructions, and he returned
to the hospital three days later with an infection that was even
worse—and now he has sepsis. As you know, that's a serious red
flag. Care coordinators need to be seriously concerned with
readmission rates, as these reflect poorly on the hospital and
impact our ability to be reimbursed by Medicare.
Mr. Decker is responding well to antibiotics, thankfully. This
afternoon, several members of the team are having a meeting to
discuss his care.
Here's what I want you to do. Go to the meeting, and just listen.
At future meetings throughout your internship, you'll offer your
feedback, but for today, I just want you to be a "fly on the
wall." Afterwards, you'll meet with me. I'll ask you some

questions about the meeting and provide you with some
feedback.
Thanks for all your hard work!
Denise
Panel Discussion
It looks like you’ll be listening in on a meeting.
Vicki: So, Seth, you were the case coordinator who was working
with Mr. Decker and his family. Can you tell me what
happened?
Seth: Well, as you know, Mr. Decker came in with a badly
infected toe. He was diagnosed with diabetes last year. It
sounds like he hasn't been treating it effectively.
Vicki: Why do you say that?
Lucas: I spoke with Mr. Decker and his wife. It sounds like he's
been forgetting to take his insulin. He said that's only happened
twice, but I got the sense from his wife that it happens fairly
often. Plus they both told me his diet hasn't changed much since
the diagnosis. He's lost about 10 pounds, which is great. But
he's still in the obese range.
Vicki: That's too bad. Was the toe infection related to the
diabetes?
Seth: It was probably a factor. He cut his toe while walking his
dog. His wife washed the cut and put a bandage on it. But it got
worse. A nephew finally took him to his primary physician,
since he and his wife don't drive on freeways anymore. The
physician sent Mr. Decker to the hospital.
Vicki: So explain to me what happened when Mr. Decker came
here the first time.
Seth: Mr. Decker was given antibiotics and the infection started
to clear up after a two-day stay. Medicare wanted to send him
home with antibiotics. We weren't aware that his toe wound had
progressed and he had developed a more resistant infection.
Vicki: That's too bad. Samantha, what was your involvement in
this case?
Samantha: I met with Mr. and Mrs. Decker. I was definitely

concerned that Mr. Decker wouldn't take the antibiotics if we
sent him home. He also needed to treat the infection site twice a
day. Mrs. Decker assured us that us that she would take care of
her husband and make sure the infection was treated. But I was
leery because it doesn't sound like the diabetes or the original
cut was treated very well.
Vicki: So why was he sent home?
Seth: Well, for one thing, we talked to the Deckers' nephew —
the one who drove him to the doctor and the hospital. He said
that his wife was a stay-at-home mom and that she could stop by
twice a day to take care of Mr. Decker. Apparently this couple
lives in the same neighborhood as the Deckers. Also, the
Deckers' daughter was planning to fly in from California later
that week to take care of him.
Vicki: Did that happen?
Seth: No. Apparently there was a last-minute emergency at the
daughter's workplace, so she wasn't able to come. And it's
unclear to me how often the nephew and his wife stopped by.
Samantha: Yeah. I spoke with the nephew. Apparently his wife
wasn't happy about being volunteered for this situation. It
sounds like she only stopped by a few times.
Vicki: So now Mr. Decker is back. It sounds like he is
responding well to the new round of antibiotics.
Seth: Thankfully, yes. At first we thought an amputation might
be necessary. But he's doing remarkably well. He might be able
to go home next week—except that we know that's not a
realistic option.
Vicki: So what's next?
Samantha: The Deckers don't have the resources to pay for
much that Medicare won't cover. A rehabilitation center might
be a good option, but it will be a challenge to find one they can
afford. Other options would be home health care or an
outpatient infusion center.
Vicki: Seth and Samantha, what are your thoughts about the
outpatient infusion center?
Seth: At this point, I think that's the best option. Mr. Decker

doesn't need rehabilitation. He just needs someone to administer
the antibiotics.
Samantha: I actually think a skilled nursing facility might be
the better option. We've seen that the Deckers aren't able to
handle this themselves, and that they don't have a good enough
support system to help. The infusion center would only help
with the antibiotics. We need to make sure the infection site is
cared for and that he gets some help with his diabetes as well.
Seth: But that's an expensive option they may not be able to
afford—and I don't think that level of care is necessary.
Samantha: But I just can't picture sending Mr. Decker home yet.
I'm afraid he'll wind up back here again—or worse.
Post Discussion Interview
So, you were a fly on the wall for the meeting about Fred
Decker. It looks like he’ll be cleared to leave the hospital next
week. The team needs to recommend a course of action for him.
What do you think should happen next?
That's certainly one option. But what if the Deckers can't afford
it?
If the Deckers might have difficulty affording a rehabilitation
facility, what step do you recommend next?
Research options. Look for a rehabilitation facility that they can
afford.
Good point. Forget it—let’s go with the outpatient infusion
center.
That’s certainly one option. Let’s assume the outpatient
infusion center is covered by Medicare. Do you have all the
information you need before recommending this option?
In the conversation among your colleagues, Seth favored the
outpatient infusion center. What step do you recommend next?
Seth is right. Send Mr. Decker to the outpatient infusion center.
There’s an important question that nobody asked.
I would definitely do this. It sounds like Mr. Decker might not
do so well at home yet. Make some phone calls. However, be

prepared for the possibility that they won’t be able to afford a
rehabilitation facility. You’ll need to consider other options as
well—like an outpatient infusion center.
Do you think Seth made the right choice in recommending that
Mr. Decker be sent home after his first hospital visit?
Yes. There was reason to believe that Mr. Decker had enough
help—his daughter was coming, and his nephew said they would
help.
No. he should have stayed in the hospital.
Don’t give up so easily. Make some phone calls and look for a
facility they can afford. I have my doubts that this patient is
ready to go home yet. You may be right, and you might need to
go with the outpatient infusion center, but see what’s out there
first.
help.
I agree that the outpatient infusion center is probably a good
choice. But nobody asked about transportation. Remember —the
Deckers aren't driving much anymore, and it doesn't sound like
they have a reliable neighbor or relative to take them. Before
recommending this option, you should research medical
transport companies to find out if this is a good option for
getting Mr. Decker to his appointments. Or find out if there's a
facility close to their home that Mrs. Decker feels comfortable
driving to.
Also, I wouldn't give up on the rehabilitation facility idea. Call
around and see if you can find a facility Mr. Decker can afford.
Sending him home right now might not be the best idea if
there's an affordable alternative.

help.
That's right. I agree that the outpatient infusion center is
probably a good choice. But nobody asked about transportation.
Remember—the Deckers aren't driving much anymore, and it
doesn't sound like they have a reliable neighbor or relative to
take them. Before recommending this option, you should
research medical transport companies to find out if this is a
good option for getting Mr. Decker to his appointments. Or find
out if there's a facility close to their home that Mrs. Decker
feels comfortable driving to.
Also, I wouldn't give up on the rehabilitation facility idea. Call
around and see if you can find a facility Mr. Decker can afford.
Sending him home right now might now be the best idea if
there's an affordable alternative.
help.
You may be right. Should Seth have done more to make sure
that Mr. Decker had enough care at home?
Do you think Seth should have done more?
No. It's too bad things went wrong, but Seth covered all his
bases.
Seth should have investigated the situation further.
That might have been the best choice if it weren't for financial
considerations. The hospital can't keep people here indefinitely.
Can you think of some other alternatives?
What alternative to an extended hospital stay do you
recommend?
A home health care service should have been investigated.
He could have been sent home, but Seth should have followed
up to make sure he was getting the care he needed.

On the one hand, case managers can't be expected to anticipate
every possible problem—like the last-minute work emergency
that made it impossible for the daughter to fly out here. On the
other hand, I do think Seth could have investigated a little
further. He could have spoken with the daughter to make sure
her flight plans were concrete—and followed up to make sure
she arrived. And I especially think Seth could have talked to the
nephew's wife, instead of relying on the nephew's promise that
his wife would help out.
I agree. He could have contacted Mr. Decker's daughter and his
nephew's wife. Those were the two people who were supposed
to provide assistance, but Seth didn't speak to them personally.
That's a good idea. It might not have been affordable, but I
agree that option could have been explored. There was enough
evidence that Mr. Decker and his wife were not able to care for
his infection alone, and no proof that anyone reliable was
available to help them.
That's a good choice. If Seth had followed up on this case, he
would have discovered that home care was not working. He then
could have explored other options, like a rehabilitation facility
or an outpatient infusion center.
Conclusion
You have completed the Nurse's Role in Care Coordination
activity. Now that you have spent your first day on the job at St.
Anthony Medical Center, you should be able to:
· Summarize the roles that case managers and other team
members play in care coordination.
· Contextualize care coordination and today's care coordination
trends historically.

1 Comprehensive Needs Assessment L

1 Comprehensive Needs Assessment L

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