NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

For Marta Rodriguez, the integration of HIT into her care plan ensures that her clinical records are accurate, comprehensive, and reflective of her health behaviors. These systems enable healthcare professionals to personalize Marta’s treatment, improving care coordination and outcomes. Through real-time access and HIT-enabled collaboration, providers can offer targeted interventions and monitor progress effectively, ensuring Marta receives continuous and efficient care across all points in her treatment journey.

The use of HIT is especially critical in transitional care planning. As Marta moves from inpatient care to recovery at home, tools like EHRs and communication platforms help ensure that her interdisciplinary care team remains aligned. The centralization of data through HIT supports tailored and proactive care management, reducing the risk of readmission and enhancing Marta’s overall healthcare experience.

Scenario

Marta Rodriguez, a freshman university student who moved from New Mexico to Nevada, faced a significant health challenge following a severe accident. She endured several surgeries and a prolonged hospital stay to manage a systemic infection. As a Spanish-speaking patient, Marta’s care coordination also requires cultural sensitivity and language-appropriate communication. Given her reliance on a student health insurance plan and her new living arrangement with extended family, comprehensive discharge planning is essential to support her recovery.

As the senior care coordinator, my responsibility is to oversee Marta’s transition from the hospital to her home setting. Effective discharge planning involves aligning all facets of Marta’s care through interdisciplinary collaboration, leveraging HIT to communicate clearly and accurately across team members. HIT tools allow for real-time information sharing, which is crucial to tailoring a plan that suits Marta’s medical, cultural, and logistical needs.

By implementing informatics tools, the care team ensures a smoother discharge experience for Marta. Patient education resources can be delivered digitally in her preferred language, follow-up appointments can be scheduled online, and medication adherence can be monitored remotely. These steps help mitigate the risk of complications and support Marta’s recovery in a cost-effective and patient-centered manner.

Longitudinal Patient Care Plan

To design an effective longitudinal care plan for Marta, a combination of EHRs and care coordination platforms will be employed. EHRs provide a centralized and accessible record of Marta’s treatment history, medications, surgical interventions, and care preferences. These records allow for informed decision-making and ensure consistent care delivery across various healthcare settings. By aligning care with Marta’s clinical history, EHRs support the goal of enhancing the patient experience as defined in the Triple Aim framework (Reza et al., 2020).

In addition, platforms such as CareTeam, CareCognize, and CareMessage facilitate real-time collaboration among care providers. These tools allow the interdisciplinary team to manage appointments, communicate about Marta’s progress, and coordinate care plans seamlessly. The integration of these tools enhances the team’s ability to respond promptly to Marta’s changing health needs and deliver personalized care effectively (de Witt et al., 2020).

Advanced technologies will further support post-discharge care. Devices for remote monitoring, such as wearables tracking heart rate or blood pressure, help clinicians stay informed about Marta’s condition. Telehealth platforms enable Marta to consult with her providers without leaving home, reducing barriers to access. Together, these technologies help decrease the likelihood of readmission within 48 hours and align with the population health objective of the Triple Aim by improving long-term health outcomes (Coffey et al., 2022).

Table 1

Technologies Supporting Marta’s Longitudinal Care

Data Reporting Pertinent to Client Behaviors

HIT-enabled data reporting plays a transformative role in care coordination, allowing providers to track and respond to patient-specific behaviors. By analyzing behavioral trends such as medication adherence or appointment attendance, care teams can promptly address any issues and tailor support strategies for Marta. For example, if Marta’s records indicate inconsistent medication use, targeted interventions like medication reminders or virtual counseling can be implemented (Ogundipe, 2024).

Data reporting also strengthens care management by providing measurable outcomes and feedback loops. If Marta’s health metrics or behavioral patterns suggest a treatment isn’t effective, clinicians can swiftly revise her care plan. This proactive management approach increases efficiency and ensures that Marta receives care aligned with her evolving needs (World Health Organization, 2021).

Moreover, clinical efficiency is improved through data-informed decision-making. Identifying patterns such as frequent emergency visits allows providers to implement preventive measures, reducing resource use and improving Marta’s experience. Data also fosters interprofessional innovation—by sharing insights, healthcare teams can develop more adaptive, personalized care models that support Marta’s recovery journey (McLaney et al., 2022).

Table 2

Evaluation Criteria for Data Quality in Marta’s Case

Using Client Records to Positively Influence Health Outcomes

The structured use of client records through HIT systems enhances health outcomes by offering real-time, data-driven insights. Marta’s records offer a holistic view of her condition—from the initial accident to her current treatment. This level of detail supports the development of personalized care plans that adapt to her clinical and social context (Aminabee, 2024). HIT ensures that all members of her care team have access to the same information, reducing communication gaps and ensuring treatment consistency across various settings.

Seamless transitions between providers are crucial in preventing care fragmentation. For example, when Marta sees a new specialist, her EHR provides full transparency of previous treatments, diagnoses, and medications. This eliminates redundancy, avoids potential medication conflicts, and improves treatment accuracy (Vos et al., 2020).

Further, client records enhance evidence-based care. Analyzing Marta’s health data—such as glucose levels, weight, or mobility trends—can highlight areas for intervention. The care team can then adjust her plan to optimize outcomes, whether by modifying medications or integrating lifestyle coaching (Ruaya, 2023). This ensures that care decisions are grounded in real data and tailored to Marta’s specific needs.

Assumptions

The effective use of HIT is based on the assumption that such systems improve care coordination, ensure personalized care, and ultimately enhance health outcomes. Marta’s care team inputs observations, treatment notes, and progress updates into her EHR, enabling real-time collaboration among professionals (Okolo et al., 2024). These systems allow providers to track progress, share concerns, and implement timely changes.

Additionally, secure messaging features in HIT platforms support open communication, allowing professionals to consult on Marta’s care in a secure and timely manner. This contributes to better planning and intervention, reducing delays and increasing the accuracy of care decisions (Machon et al., 2020). As a result, HIT tools not only improve documentation but also create a collaborative environment focused on the patient’s well-being.

Conclusion

The integration of HIT into Marta Rodriguez’s discharge and ongoing care plan ensures that her health data is accurate, comprehensive, and actionable. HIT systems facilitate care coordination by providing access to centralized information, enabling providers to make personalized and evidence-based decisions. These tools support patient engagement, minimize the risk of readmission, and foster clinical efficiency. Ultimately, the thoughtful use of HIT leads to improved healthcare experiences and outcomes for Marta.

References

Aminabee, S. (2024). The future of healthcare and patient-centric care: Digital innovations, trends, and predictions. IGI Global. https://www.igi-global.com/chapter…

Avdagovska, M., Ballermann, M., Olson, K., & Nitsch, K. (2020). The use of MyChart by patients with multiple chronic conditions: Qualitative study. JMIR Medical Informatics, 8(12), e21598. https://doi.org/10.2196/21598

Coffey, J. D., et al. (2022). Telehealth and remote monitoring in post-discharge care: Reducing readmission risks. Journal of Telemedicine and Telecare, 28(1), 25–34.

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

de Witt, J., McConnell, H., & Fabian, A. (2020). Interprofessional care coordination using digital health platforms. Healthcare Technology Letters, 7(2), 40–48.

Machon, C., Henderson, J., & Lopez, A. (2020). Secure communication in clinical coordination: Best practices. Nursing Management, 51(7), 24–30.

McLaney, E., Chavez, L., & O’Donnell, K. (2022). Innovation in interprofessional teams through data sharing. Health Systems Management Journal, 36(4), 310–317.

Ogundipe, O. (2024). Behavioral data and coordinated care: Trends and tools. Global Journal of Health Informatics, 12(1), 45–52.

Okolo, T., Zhang, Q., & Ferris, M. (2024). Real-time EHR collaboration: Enhancing care transitions. Medical Informatics Quarterly, 18(3), 172–181.

Reza, S. M., Johnson, J. L., & Bailey, T. (2020). EHR and Triple Aim integration in patient-centered care. Health Services Research, 55(S2), 180–193.

Ruaya, S. (2023). Data-driven care planning for chronic conditions. Clinical Informatics Review, 14(1), 89–98.

Sheikh, A., Sood, H. S., & Bates, D. W. (2021). Leveraging HIT to improve quality and safety. BMJ Quality & Safety, 30(5), 387–390.

Sutton, R. T., & Pincock, L. (2020). Decision support systems in modern healthcare. Journal of Biomedical Informatics, 104, 103456.

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Tolley, C., Anderson, M., & Reid, S. (2023). Efficiency metrics in clinical settings using EHRs. Health Informatics Journal, 29(2), 221–232.

Vos, J., Marshall, H., & Richards, E. (2020). The role of electronic records in care transitions. Journal of Nursing Administration, 50(9), 479–485.

World Health Organization. (2021). Global patient safety action plan 2021-2030: Towards eliminating avoidable harm in health care. World Health Organization.