NURS FPX 6614 Assessment 1 Defining a Gap in Practice

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Capella university

NURS-FPX 6614 Structure and Process in Care Coordination

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Date

Defining a Gap in Practice: Executive Summary

This assessment explores the use of Electronic Health Records (EHRs) in enhancing care coordination for adult patients with chronic diseases. Through the development of a well-structured Population, Intervention, Comparison, Outcome, and Time (PICOT) question, this initiative identifies a current gap in practice. The overarching goal is to present an executive summary that informs healthcare decision-makers about critical components necessary for improving coordination among providers. Effective communication facilitated through technology-driven solutions like EHRs offers a practical way forward in addressing fragmented care processes often observed in managing chronic conditions.

The pressing need for systemic change stems from observable delays and inefficiencies in care coordination due to limited technological integration. This executive summary advocates for a centralized EHR framework that bridges interprofessional gaps and provides a holistic view of patient history. By highlighting the implications of technological underuse in chronic disease management, this executive summary underscores the urgency to act and adopt evidence-based digital solutions. Centralized record-keeping ensures timely access to health data and supports informed decision-making across multidisciplinary teams.

The summary promotes an integrative and strategic response tailored to the healthcare organization’s needs. Decision-makers are encouraged to consider pilot programs, stakeholder training, and systems testing as integral components of the transition toward comprehensive digital coordination tools. The emphasis on measurable outcomes, including reduced hospital readmission rates and enhanced patient outcomes, supports the proposal’s alignment with quality improvement goals.

Analysis of Clinical Priorities and PICOT Application

Clinical Priorities in Chronic Disease Management

Managing adults with chronic illnesses requires attention to a spectrum of clinical priorities to ensure effective and coordinated care. Conditions such as diabetes, hypertension, cardiovascular diseases, and chronic respiratory disorders dominate the health landscape and require ongoing assessment, medication adherence, and lifestyle changes (Kompaniyets, 2021). Emphasis on preventive strategies, including vaccinations, routine checkups, and dietary interventions, plays a pivotal role in slowing disease progression.

In addition to clinical tasks, healthcare providers face the challenge of overcoming gaps in care coordination. These include suboptimal information exchange and lack of real-time communication across care teams. The absence of integrated digital tools, such as EHRs, often contributes to fragmented services and inconsistent patient tracking. Addressing these obstacles with technological aids like telehealth or secure digital records can substantially improve patient monitoring and communication (Lewinski et al., 2022).

PICOT Question Framework

A well-crafted PICOT question enables a focused approach to evaluating practice change:

PICOT Element	Description
Population (P)	Adults with chronic diseases in local healthcare settings
Intervention (I)	Implementation of a centralized Electronic Health Record system
Comparison (C)	Absence of technology-based coordination
Outcome (O)	Improved care coordination
Time (T)	Within two years

This structured inquiry highlights how centralizing EHR usage can significantly impact communication, coordination, and outcomes in chronic care. Evidence supports that EHR systems streamline the sharing of patient data among professionals, reducing the likelihood of fragmented treatment and repeated admissions (Watterson et al., 2020; Manov et al., 2020). Thus, adopting this framework could mark a strategic leap forward in chronic care delivery.

Interventions, Resources, and Outcome Planning

Evaluation of Resources and Services

A range of services and technological tools can enhance care coordination for chronic disease management. These include EHRs, telehealth systems, remote monitoring tools, and patient engagement platforms such as mobile applications and portals. When fully integrated into healthcare workflows, these resources facilitate real-time communication and continuous health tracking (Fjellså et al., 2022). Below is a comparative overview:

Resource	Function	Benefit
EHR	Centralized record system	Enhances provider communication
Telehealth	Virtual consultations	Increases access to care remotely
Patient Portals	Health data access for patients	Promotes self-management
Mobile Apps	Symptom tracking and reminders	Boosts adherence and communication

While beneficial, these tools face implementation barriers such as data security concerns, varying technology competencies among users, and inconsistent internet access in underserved regions (Lewinski et al., 2022). Addressing these limitations through comprehensive training and robust IT support is essential for successful integration.

Care Coordination Intervention: Clinical Pathways

To improve care coordination among adults with chronic illnesses, implementing clinical pathways serves as a structured and evidence-based solution. These multidisciplinary plans standardize care delivery, reduce variability in practice, and enhance adherence to best practices (Bardhan et al., 2020). The process begins with forming interprofessional teams, reviewing current guidelines, and customizing protocols tailored to the chronic conditions most prevalent within the patient population.

Integration into EHR systems further enhances the efficiency of clinical pathways, allowing for seamless tracking and documentation. This digital alignment ensures every member of the care team operates with current and consistent information, fostering coordinated and proactive patient care. Moreover, it simplifies the monitoring of quality metrics and patient progress across encounters.

Collaborative Strategy and Nursing Diagnosis

The primary nursing diagnosis identified is “ineffective self-health management” among adults with chronic conditions. This diagnosis signals a lack of patient capacity to manage health effectively due to barriers such as limited knowledge, poor support systems, and uncoordinated care. A collaborative care model is vital to addressing this challenge. Educational materials, tailored guidance, and supportive counseling can empower patients to take ownership of their health (Orrego et al., 2021).

Furthermore, technology plays a crucial role in collaboration. For instance, shared access to EHRs enables consistent messaging across providers, while mobile applications allow patients to engage with their care plans. Nurses and other professionals can monitor progress and provide real-time feedback, further enhancing the continuity of care (Fjellså et al., 2022).

Planning for Implementation and Measuring Outcomes

Implementing a coordinated care model begins with identifying and engaging all relevant stakeholders, including clinicians, IT specialists, administrators, and patients. Partnering with EHR vendors ensures the customization of platforms for chronic care needs. Adequate training ensures that all users are proficient in the technology and that the transition aligns with operational workflows.

Protocols will be co-developed and shared across teams to create uniformity in care coordination. Pilot testing phases can identify bottlenecks and areas needing refinement. Below are the expected outcomes of this initiative:

Outcome	Description
Improved Communication	Timely information exchange among care teams
Enhanced Efficiency	Reduced duplication and better resource use
Higher Patient Engagement	Patients more involved in their health journey
Fewer Adverse Events	Improved medication management and monitoring
Better Health Outcomes	Reduced readmissions and stabilized chronic conditions

A key assumption is that stakeholder buy-in and continuous evaluation will drive sustained success. Regular feedback loops and technical support systems are essential in ensuring the durability and impact of this intervention (Watterson et al., 2020).

References

Bardhan, I., Chen, H., & Karahanna, E. (2020). Connecting systems, data, and people: A multidisciplinary research roadmap for chronic disease management. MIS Quarterly: Management Information Systems, 44(1), 185–200. https://doi.org/10.25300/MISQ/2020/14644

Fjellså, H. M. H., Husebø, A. M. L., & Storm, M. (2022). EHealth in care coordination for older adults living at home: Scoping review. Journal of Medical Internet Research, 24(10), e39584. https://doi.org/10.2196/39584

Kompaniyets, L. (2021). Underlying medical conditions and severe illness among 540,667 adults hospitalized with COVID-19, March 2020–March 2021. Preventing Chronic Disease, 18. https://doi.org/10.5888/pcd18.210123

NURS FPX 6614 Assessment 1 Defining a Gap in Practice

Lewinski, A. A., Walsh, C., Rushton, S., Soliman, D., Carlson, S. M., Luedke, M. W., Halpern, D. J., Crowley, M. J., Shaw, R. J., Sharpe, J. A., Alexopoulos, A.-S., Tabriz, A. A., Dietch, J. R., Uthappa, D. M., Hwang, S., Ball Ricks, K. A., Cantrell, S., Kosinski, A. S., Ear, B., & Gordon, A. M. (2022). Telehealth for the longitudinal management of chronic conditions: Systematic review. Journal of Medical Internet Research, 24(8), e37100. https://doi.org/10.2196/37100

Manov, N. F., Srulovici, E., Yahalom, R., Perry-Mezre, H., Balicer, R., & Shadmi, E. (2020). Preventing hospital readmissions: Healthcare providers’ perspectives on “impactibility” beyond EHR 30-day readmission risk prediction. Journal of General Internal Medicine, 35(5), 1484–1489. https://doi.org/10.1007/s11606-020-05739-9

Orrego, C., Ballester, M., Heymans, M., Camus, E., Groene, O., Niño de Guzman, E., Pardo‐Hernandez, H., & Sunol, R. (2021). Talking the same language on patient empowerment: Development and content validation of a taxonomy of self‐management interventions for chronic conditions. Health Expectations. https://doi.org/10.1111/hex.13303

Watterson, J. L., Rodriguez, H. P., Aguilera, A., & Shortell, S. M. (2020). Ease of use of electronic health records and relational coordination among primary care team members. Health Care Management Review, 45(3), 1. https://doi.org/10.1097/hmr.0000000000000222

NURS FPX 6614 Assessment 1 Defining a Gap in Practice