NURS FPX 6616 Assessment 1 Community Resources and Best Practices.pdf

Assessment 1: Community Resources and Best Practices
Student Name
Capella University
NURS-FPX 6616 Ethical and Legal Considerations in Care Coordination
Prof. Name
June 26, 2024
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Addressing Community Challenges with Effective Solutions
Welcome, colleagues. Today, we focus on a critical issue within our healthcare system:
the rising rates of patient readmissions. We will evaluate our existing practices, explore
the legal and ethical considerations involved, and propose the Transitional Care Model
(TCM) as a viable solution. Our aim is to identify obstacles, develop collaborative
strategies to enhance care quality, improve patient outcomes, and fulfill our ethical
obligations while mitigating legal risks. Thank you for joining us in this crucial effort
toward innovation and improvement.
Slide 2: Presentation Objectives
This presentation aims to thoroughly investigate the issue of high readmission rates in
our healthcare facility. We will discuss the gravity and effects of this problem, including
its legal and ethical dimensions. Additionally, we will introduce the Transitional Care
Model (TCM), a research-backed approach with the potential to significantly improve
patient outcomes. This session is intended as a collaborative space to develop practical
strategies that will enhance our healthcare services, lower readmission rates, and
ensure we meet our legal and ethical responsibilities. Through this discussion, we strive
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to advance patient care and create a more effective, ethically guided healthcare
organization.
Slide 3: Examination of Current Issues and Challenges
In the past year, our hospital discharged 10,000 patients, of whom 2,000 (20%) were
readmitted within 30 days. Data reveals a concerning increase in readmission rates
among patients with chronic conditions, particularly those with heart disease and
diabetes, which together account for 50% of readmissions. Specifically, patients with
heart disease have a 35% readmission rate, while those with diabetes have a 30% rate.
These figures suggest potential deficiencies in our care delivery and post-discharge
processes, with each readmission representing a significant setback for patients and
their families.
The use of healthcare information systems (HCIS) for care coordination raises ethical
concerns, especially regarding patient confidentiality. Despite secure designs, the risk of
data breaches—whether accidental or due to cyber-attacks—remains significant. The
sensitivity of healthcare data means that breaches can lead to severe emotional, social,
and financial consequences for patients. Ethical issues also arise with informed
consent, particularly about the use and sharing of patient data. Although systems
generally require broad consent, questions persist about patients’ understanding of
these implications. Additionally, HCIS adoption might exacerbate health disparities,
potentially benefiting more tech-savvy patients while disadvantaging groups such as the
elderly or low-income individuals, raising concerns about fairness and equity.
Algorithmic decision-making further complicates ethical considerations, as biases may
unintentionally impact personalized care. Balancing HCIS use with ethical principles is
an ongoing challenge.
Slide 4: Legal and Ethical Considerations
High readmission rates carry legal implications, potentially exposing the hospital to
malpractice claims for perceived negligence. Insufficient post-discharge instructions
can worsen patient conditions, leading to legal consequences that affect both financial
and reputational aspects. Additionally, non-compliance with the Hospital Readmissions
Reduction Program (HRRP) by the Centers for Medicare and Medicaid Services (CMS)
can result in financial penalties, significantly reducing Medicare reimbursements.
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From an ethical perspective, high readmission rates raise concerns about our
commitment to delivering optimal patient care. Healthcare providers have a moral
obligation to ensure comprehensive, effective treatment and robust post-discharge
support. Failing to meet this obligation affects patient health outcomes and undermines
trust in our services. Addressing high readmission rates is essential for fulfilling our
ethical responsibilities to patients.
Slide 5: Effective Strategies and Comparison to Current Practices
A review of literature and benchmarking against high-performing hospitals highlights
promising strategies to reduce readmission rates, particularly through improved care
coordination and personalized patient education. Currently, our care coordination
focuses mainly on hospital settings, with healthcare teams developing discharge plans.
However, outcomes indicate inadequate long-term compliance and post-discharge
support, coupled with moderate patient satisfaction ratings. In contrast, hospitals with
lower readmission rates utilize proactive care coordination models, featuring dedicated
teams for customized discharge plans and follow-up. These proactive strategies enable
timely management of complications, thus reducing readmission risks.
Regarding patient education, current practices involve standardized discharge materials,
which may be insufficient. Tailoring education to individual patient needs,
comprehension levels, and lifestyles improves understanding and adherence, thereby
reducing readmission rates. Adopting these best practices can enhance our legal and
ethical responsibilities. Proactive care coordination and personalized education not only
reduce negligence claims but also prioritize patient well-being, reinforcing our
commitment to high-quality, patient-centered care.
Slide 6: Evidence-Based Intervention and Stakeholder Engagement
The Transitional Care Model (TCM) is an evidence-supported intervention with potential
to reduce readmissions. Developed by Dr. Mary Naylor and colleagues, TCM has
demonstrated significant success in lowering readmission rates among chronically ill
older adults. TCM involves comprehensive planning during hospitalization and
home-based follow-up, leading to reduced readmissions, improved health outcomes,
and lower healthcare costs.
Stakeholders impacted by TCM implementation include individuals and organizations.
Patients benefit from personalized care and thorough follow-up, particularly those with
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chronic conditions. Healthcare providers—such as physicians, nurses, and care
coordinators—play critical roles and require training and potential restructuring. External
stakeholders like insurers and policy-making bodies such as CMS may also be
influenced by reduced readmissions, impacting reimbursement policies.
Slide 7: Interprofessional Team Dynamics in the Intervention
Successful implementation of TCM relies on strong interprofessional collaboration,
leveraging the expertise of various healthcare professionals. Physicians oversee
medical care, ensuring patient needs are integrated into care plans. Nurses focus on
transitional care, bridging gaps between patients and healthcare systems. Care
coordinators facilitate smooth transitions across care settings, while social workers
address social determinants of health, ensuring comprehensive patient support beyond
medical needs. Effective interprofessional teamwork enhances patient outcomes and
reduces readmission rates, with TCM's success depending on the collective efforts of
healthcare professionals.
Slide 8: Approach to Baseline Data Assessment
Our hospital’s readmission rate for chronic disease patients is 25%, exceeding the
national average of 15%. This discrepancy underscores the need for a well-defined
intervention strategy. Implementing TCM requires specific measures to assess
effectiveness. Key Performance Indicators (KPIs) are essential:
● Readmission Rates: Ongoing monitoring of 30-day readmission rates.
● Patient Satisfaction Scores: Evaluation of patient perceptions through surveys.
● Hospital Stay Duration: Tracking average lengths of stay.
● Overall Cost of Care: Assessing financial impacts.
Regular evaluations will help identify trends and refine strategies.
Slide 9: Evaluation Periods and Methodology
A robust evaluation strategy is crucial for monitoring TCM’s impact. Quarterly
evaluations during the first year and semi-annual assessments thereafter will facilitate
progress tracking, issue identification, and strategy refinement. Data from various
sources—patient records and surveys—will undergo statistical analysis for reliable
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insights. Frequent evaluations will support data-driven adjustments, ensuring effective
implementation and improved outcomes.
Slide 10: Recommendations for Sustaining Intervention Results
To maintain improvements achieved through TCM, ongoing staff development,
interprofessional communication, procedural reassessment, and patient feedback are
essential:
● Continuous Staff Development: Regular training to uphold best practices.
● Consistent Interprofessional Communication: Routine meetings to address care
gaps.
● Procedural Reassessment: Annual audits to align with evolving standards.
● Continuous Patient Feedback: Regular surveys to enhance patient-centered care.
Slide 11: Conclusion
In conclusion, addressing high readmission rates requires a comprehensive approach
that combines evidence-based interventions like TCM with rigorous evaluation and
sustained efforts. Interprofessional collaboration and stakeholder engagement are key
to success. By prioritizing patient welfare, adhering to legal and ethical standards, and
striving for excellence, we can effectively reduce readmission rates and improve patient
outcomes.
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References
Bianco, G. L., Tinnirello, A., Papa, A., Marchesini, M., Day, M., Palumbo, G. J., Terranova,
G., Dato, M. T. D., Thomson, S. J., & Schatman, M. E. (2023). Interventional pain
procedures: A narrative review focusing on safety and complications. Part 2
interventional procedures for back pain. Journal of Pain Research, 16, 761–772.
https://doi.org/10.2147/JPR.S396215
Fountoulaki, K., Ventoulis, I., Drokou, A., Georgarakou, K., Parissis, J., & Polyzogopoulou,
E. (2022). Emergency department risk assessment and disposition of acute heart failure
patients: Existing evidence and ongoing challenges. Heart Failure Reviews.
https://doi.org/10.1007/s10741-022-10272-4
O’Donnell, L., George, E., Donnelly, J., Bilderback, A., & Buchanan, D. (2023). Coaching to
bedside shift report and its correlation to hospital consumer assessment of healthcare
providers and systems and value-based purchasing dimension scores. JONA: The
Journal of Nursing Administration, 53(1), 12–18.
https://doi.org/10.1097/nna.0000000000001236#
Renouf, T., Bates, A., Davis, J. F., & Jack, S. (2022). Prehabilitation. An interdisciplinary
patient-centric conceptual framework. Seminars in Oncology Nursing, 151329.
https://doi.org/10.1016/j.soncn.2022.151329
Suksatan, W., & Tankumpuan, T. (2021). The effectiveness of transition care
interventions from hospital to home on rehospitalization in older patients with heart
failure: An integrative review. Home Health Care Management & Practice,
108482232110238. https://doi.org/10.1177/108482232
11023887
Wright, B., Parrish, C., Basu, A., Joynt, K. E., Liao, J. M., & Sabbatini, A. K. (2023).
Medicare’s hospital readmissions reduction program and the rise in observation stays.
Health Services Research. https://doi.org/10.1111/1475-6773.14142
Zumbrunn, A., Bachmann, N., Bayer-Oglesby, L., & Joerg, R. (2022). Social disparities in
unplanned 30-day readmission rates after hospital discharge in patients with chronic
health conditions: A retrospective cohort study using patient level hospital
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administrative data linked to the population census in Switzerland. PLOS ONE, 17(9),
e0273342. https://doi.org/10.1371/journal.pone.0273342
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