NURS FPX 6610 Assessment 2 Patient Care Plan

Name

Capella university

NURS-FPX 6610 Introduction to Care Coordination

Prof. Name

Date

Comprehensive Needs Assessment

A comprehensive needs assessment is a foundational tool for healthcare professionals, enabling them to systematically evaluate the requirements of patients and identify areas where care delivery can be optimized. This assessment is particularly essential in situations where patients present with complex, multifactorial issues requiring multidisciplinary intervention. Through this process, providers can determine the existing deficiencies in care and implement effective strategies to bridge these gaps.

The approach encompasses identifying physiological, social, and psychological components of health, thereby supporting a more inclusive care model. By leveraging tools such as the Patient-Centered Assessment Method (PCAM), professionals can gain deeper insight into patient experiences, beliefs, and conditions, which enhances the personalization of care plans (Perazzo et al., 2020). Such assessments stress the need for collaboration across medical, emotional, and logistical aspects of care, laying the foundation for improved outcomes.

Interdisciplinary collaboration is another key component of a successful needs assessment. Coordinated efforts among healthcare professionals, such as nurses, social workers, and physicians, ensure a seamless transition across care settings. This integrated model boosts care continuity, reduces avoidable complications, and increases patient satisfaction, thus improving the overall standard of care.

Current Gaps in the Patient’s Care

In Mr. Decker’s case, several shortcomings in care coordination and discharge planning were evident. These gaps have adversely affected his recovery process, leading to a hospital readmission that might have been preventable with proper planning and communication.

Table 1: Identified Gaps in Patient’s Care

Identified Gaps	Details
Financial Constraints	Mr. Decker’s low-income status limits access to advanced treatments.
Post-Discharge Knowledge Gap	Inadequate discharge instructions led to a critical infection going untreated.
Follow-Up Deficiencies	The absence of consistent follow-up care worsened his health condition.

The use of PCAM played a crucial role in evaluating Mr. Decker’s case, helping providers understand his medical, emotional, and cultural circumstances. This patient-centric model acknowledges the broader determinants of health, making it ideal for aligning care delivery with the specific realities faced by older patients (Perazzo et al., 2020).

To ensure optimal care, collecting comprehensive patient information is vital. This includes not just medical records but also behavioral patterns and emotional states.

Table 2: Informational Needs for Effective Care

Required Data	Details
Medical Records	Includes age, allergies, chronic conditions, and prior treatments.
Behavioral & Emotional Insights	Covers patient values, stressors, routines, and preferences.

Additional data can be gathered through informal interviews with Mr. Decker’s family, which may reveal relevant habits or lifestyle choices. This method of data collection provides a fuller picture of patient needs, promoting tailored interventions (Mertens et al., 2020). Incorporating electronic health records—while upholding HIPAA standards—further enhances the ability to analyze historical data for continuity of care (Shah & Khan, 2020).

Societal, Economic, and Interdisciplinary Factors

Mr. Decker’s case exemplifies how societal and economic determinants influence healthcare outcomes. Elderly individuals often face a range of physiological issues like diminished immunity, hearing and vision loss, and slower recovery rates, making their care more complex (Liu et al., 2019). Additionally, financial limitations significantly affect his ability to afford necessary medications and therapies not covered by insurance.

Table 3: Factors Influencing Patient Care

Factor	Impact on Patient Care
Aging	Slower healing due to age-related health complications.
Economic Constraints	Financial hardship impedes access to supplemental care services.
Lack of Social Support	Limited assistance at home hinders adherence to medical recommendations.

The absence of social support further aggravates Mr. Decker’s condition. With minimal family involvement, his ability to comply with treatment plans is compromised, increasing the risk of complications (Ko et al., 2019).

Several professional standards serve as a foundation for improving care coordination. Notably, the National Quality Forum (NQF) offers guidelines to promote safety and efficiency in care delivery (Namburi & Lee, 2022). Meanwhile, benchmarks from the Agency for Healthcare Research and Quality (AHRQ) emphasize communication, collaboration, and patient education, which are critical during transitions of care (Artiga et al., 2020). Furthermore, the Care Coordination and Transition Model offers a framework that prioritizes personalized interventions and interdisciplinary teamwork (Hofmann & Erben, 2020).

Table 4: Professional Standards and Models

Standard/Model	Application in Care Coordination
National Quality Forum (NQF)	Provides benchmarks to elevate patient safety and systematic care.
AHRQ Benchmarks	Emphasizes education, communication, and follow-up practices.
Care Coordination & Transition Model	Supports continuity through collaborative, patient-focused strategies.

Evidence-based practices also play a crucial role in advancing care coordination. For example, the GENESIS protocol helps healthcare teams identify infections early, significantly reducing sepsis-related fatalities (Kregel et al., 2022). The “Sepsis Six” bundle offers another effective strategy, emphasizing early antibiotic use and oxygen therapy for better outcomes (Bleakley & Cole, 2020). In older patients, routine geriatric assessments provide essential insights into cognitive and functional declines, ensuring that care plans are appropriately adjusted (LeRoith et al., 2019).

Table 5: Evidence-Based Practices

Practice	Details
GENESIS Protocol	Enables early detection of infection, reducing sepsis mortality.
Sepsis Six Bundle	Standardized emergency care process for managing suspected sepsis.
Geriatric Evaluations	Monitors mental and physical health indicators in elderly populations.

A multidisciplinary care approach remains indispensable in delivering holistic and effective patient care. For Mr. Decker, involving professionals from various fields—such as nursing, psychology, and social work—ensures that all facets of his well-being are addressed. This integrated model reduces hospital readmissions and minimizes medical errors, ultimately leading to a 13% improvement in patient safety (Ni et al., 2019).

Conclusion

A structured and well-executed needs assessment forms the cornerstone of effective care coordination. In the case of Mr. Decker, addressing current gaps through interdisciplinary collaboration, informed data collection, and adherence to professional standards will significantly improve his health outcomes. Utilizing evidence-based practices and involving a diverse care team ensures that all aspects of his condition are comprehensively managed, paving the way for safer and more effective healthcare delivery.

References

Artiga, S., Orgera, K., & Pham, O. (2020). Issue brief disparities in health and health care: Five key questions and answers. Deancare.com. https://deancare.com/getmedia/e00c9856-28d0-4c63-b2c0-9bf68cadcebb/Disparities-in-Health-and-Health-Care-Five-Key-Questions-and-Answers.pdf

Bleakley, G., & Cole, M. (2020). Recognition and management of sepsis: The nurse’s role. British Journal of Nursing, 29(21), 1248–1251. https://doi.org/10.12968/bjon.2020.29.21.1248

Hofmann, F., & Erben, M. J. (2020). Organizational transition management of circular business model innovations. Business Strategy and the Environment, 29(6), 2770–2788. https://doi.org/10.1002/bse.2542

Ko, H., et al. (2019). Gender differences in health status, quality of life, and community service needs of older adults living alone. Archives of Gerontology and Geriatrics, 83, 239–245. https://doi.org/10.1016/j.archger.2019.05.009

NURS FPX 6610 Assessment 2 Patient Care Plan

Kregel, H. R., et al. (2022). The geriatric nutritional risk index as a predictor of complications in geriatric trauma patients. Journal of Trauma and Acute Care Surgery, 93(2), 195–199. https://doi.org/10.1097/TA.0000000000003588

LeRoith, D., et al. (2019). Treatment of diabetes in older adults: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 104(5), 1520–1574. https://doi.org/10.1210/jc.2019-00198

Liu, X., et al. (2019). The risk factors for diabetic peripheral neuropathy: A meta-analysis. PLOS ONE, 14(2), e0212574. https://doi.org/10.1371/journal.pone.0212574

Mertens, F., et al. (2020). Healthcare professionals’ experiences of inter-professional collaboration during patient’s transfers. Palliative Medicine, 35(2), 174–184. https://doi.org/10.1177/0269216320968741

Namburi, N., & Lee, L. S. (2022). National Quality Forum. EuropePMC. https://europepmc.org/article/med/31751044

Ni, Y., et al. (2019). Effects of nurse-led multidisciplinary team management in diabetes. Journal of Diabetes Research, 2019, 1–9. https://doi.org/10.1155/2019/9325146

Palileo-Villanueva, L. M., et al. (2022). Traditional and alternative medicine use for hypertension in low-income households. BMC Complementary Medicine and Therapies, 22(1). https://doi.org/10.1186/s12906-022-03730-x

Perazzo, M. F., et al. (2020). Patient-centered assessments in dental clinical trials. Brazilian Oral Research, 34(2). https://doi.org/10.1590/1807-3107bor-2020.vol34.0075

NURS FPX 6610 Assessment 2 Patient Care Plan

Shah, S. M., & Khan, R. A. (2020). Secondary use of electronic health record: Opportunities and challenges. IEEE Access. https://doi.org/10.1109/access.2020.301109