NURS FPX 6614 Assessment 2 Enhancing Performance as Collaborators in Care

Name

Capella university

NURS-FPX 6614 Structure and Process in Care Coordination

Prof. Name

Date

Enhancing Performance as Collaborators in Care Presentation

Welcome, everyone. I am [Your Name], and I appreciate your time in attending today’s session. This presentation focuses on the pivotal role of interprofessional collaboration in enhancing healthcare delivery—particularly for adults living with chronic conditions. One of the key gaps identified in current practice is the underutilization of Electronic Health Records (EHR) in facilitating effective care coordination. Today, we will examine strategies for strengthening interdisciplinary collaboration to improve healthcare outcomes.

1. Steps to Improve Interprofessional Collaboration

Adults with chronic illnesses require continuous, multifaceted care. Establishing an effective interprofessional framework ensures high-quality, coordinated treatment grounded in Evidence-Based Practice (EBP). Enhancing interprofessional collaboration calls for deliberate, structured actions within clinical settings.

First, healthcare leaders must clearly define each team member’s roles and responsibilities. This clarity ensures that efforts are aligned, preventing overlaps or conflicts in care delivery (Weiner et al., 2020). Once responsibilities are outlined, communication strategies must be developed and streamlined. Technologies like EHRs and patient portals enable secure, efficient information exchange among professionals, fostering transparency and collaborative decision-making (Pascucci et al., 2020).

Furthermore, it is vital to invest in ongoing training and education. These initiatives promote a deeper understanding of each discipline’s contributions to EBP and foster mutual respect across teams. Training also introduces care providers to communication tools and shared workflows that enhance chronic disease management (Pascucci et al., 2020). In addition, promoting a collaborative culture through trust-building and recognition motivates team members to contribute fully to patient care.

2. Strategic Planning

Achieving robust interprofessional collaboration requires strategic foresight. It begins with a thorough assessment of the current state of collaboration in the care facility. Leaders should conduct gap analyses to identify shortcomings in current care coordination, especially for older adults with chronic illnesses. Based on this evaluation, they can set SMART goals—Specific, Measurable, Achievable, Relevant, and Time-bound—to guide improvements (Boeykens et al., 2022).

Key aspects of strategic planning include the allocation of resources to support staff training, implementation of digital tools like EHRs, and phased rollouts beginning with a pilot unit. Once implemented, the plan must be evaluated through data-driven metrics. The quality department should compare pre- and post-implementation data such as readmission rates, patient satisfaction levels, and overall healthcare expenditure (Pascucci et al., 2020).

The strategic plan also emphasizes the importance of evidence-based assumptions. For instance, collaborative care is expected to enhance the quality of life for adults with chronic conditions like hypertension and diabetes. Technology is anticipated to bridge communication gaps, streamlining care delivery across disciplines (Davidson et al., 2022). Recognizing achievements and fostering team inclusivity are further strategies to sustain improvements.

Table 1: Key Elements of Strategic Planning for Interprofessional Care

Component	Description
Current State Assessment	Analyze existing collaboration practices
Goal Setting	Define SMART goals to improve coordination
Resource Allocation	Fund training, technology integration, pilot implementations
Quality Assurance	Use metrics (readmission, satisfaction, costs) to evaluate performance
Continuous Improvement	Address barriers and optimize team-based models

3. Educational Services and Resources for Adults with Chronic Diseases

Equipping adults with chronic conditions with adequate education is essential for self-management and collaboration with care teams. Personalized health education, tailored to each patient’s disease profile and learning preferences, improves engagement and adherence. Certified health educators play a crucial role in providing one-on-one consultations to address individual needs effectively (Huang et al., 2020).

Print resources such as brochures and pamphlets can provide easy-to-understand guidance on managing conditions, medication regimens, and available community support. Digital platforms offer additional, interactive learning opportunities. These include mobile apps, virtual support groups, video tutorials, and games that reinforce learning. The involvement of healthcare IT teams ensures that these tools are secure, accessible, and user-friendly (Agarwal et al., 2021).

The implementation of these educational services enhances patient autonomy and prepares individuals to engage with their care plans proactively. A well-informed patient is more likely to collaborate with the interprofessional team and contribute meaningfully to decision-making.

Table 2: Educational Resources for Chronic Disease Management

Resource Type	Description
Individual Plans	Custom education based on diagnosis, literacy, and preference
Print Materials	Brochures, pamphlets with actionable steps
Digital Tools	Apps, videos, quizzes, virtual groups
Health Educators	Professionals delivering one-on-one or small-group sessions

Summary of the Interprofessional Collaboration Plan

To ensure optimal management of chronic illnesses among adults, the healthcare team must commit to regular interprofessional meetings. These meetings foster collaboration, encourage open dialogue, and promote shared decision-making based on complex patient scenarios (Davidson et al., 2022). A team-based care model with clearly defined roles is fundamental in establishing clarity and accountability (Sibbald et al., 2020).

Cross-training initiatives allow professionals to better understand each other’s responsibilities, leading to enhanced mutual respect and improved communication. The integration of EHR systems facilitates asynchronous communication, ensuring care continuity without requiring physical presence (Awad et al., 2021).

The collaboration process involves evaluating patient histories, crafting coordinated care plans, and ensuring patient-centered treatment decisions. Monitoring continues during follow-up appointments to adjust treatment plans based on ongoing assessments (Pascucci et al., 2020). This cycle of planning, implementation, and review contributes to holistic and adaptive care models.

Outcomes of the New Process

Improved collaboration yields significant outcomes for adults managing chronic diseases. One key outcome is increased patient satisfaction, which stems from personalized care and improved communication between patients and providers (Pascucci et al., 2020). Secondly, hospital readmission rates decline because chronic conditions are managed proactively. A study found a 60% reduction in readmissions within 90 days of implementing team-based care (Nall et al., 2020).

Another measurable outcome is the enhanced quality of life reported by patients. Timely interventions and continuous monitoring enable the interprofessional team to adjust care plans in real time, improving disease control and patient outlook (Davidson et al., 2022).

To evaluate these improvements, healthcare facilities can perform regular audits, gather feedback from both patients and staff, and analyze relevant dashboard metrics (Rawlinson et al., 2021). Comparing these metrics to baseline values allows for assessment and continued refinement of the collaboration strategy.

Ethical Considerations

In discussing care for adults with chronic illnesses, ethical principles such as autonomy and beneficence are central. Interprofessional collaboration ensures that patients are engaged in decision-making, thereby honoring their autonomy (Lindblad, 2021). It also supports beneficence by promoting treatments aimed at improving quality of life.

Moreover, ethical care requires that patients receive the education needed to make informed decisions about their health. Transparent communication, inclusivity, and shared planning are all ethical imperatives in team-based chronic care delivery. Nonetheless, healthcare providers must be mindful of institutional and interpersonal barriers that could impede collaboration and work proactively to mitigate them (Rawlinson et al., 2021).

References

Agarwal, R., Gao, G., DesRoches, C., & Jha, A. K. (2021). Research commentary—The digital transformation of healthcare: Current status and the road ahead. Information Systems Research, 21(4), 796–809.

Aggarwal, R., Singh, M., & Arora, R. (2023). Promoting collaborative care models in chronic disease management: A qualitative study. Journal of Interprofessional Care, 37(1), 22–30.

Awad, N. I., Alaloul, F., & Al-Dossary, R. N. (2021). Electronic health records as tools for collaboration in chronic care. BMC Medical Informatics and Decision Making, 21(1), 33.

Boeykens, K., Braeken, D., & Dekens, J. (2022). Setting SMART goals to enhance team-based chronic care management. Journal of Clinical Nursing, 31(5–6), 711–720.

NURS FPX 6614 Assessment 2 Enhancing Performance as Collaborators in Care

Davidson, E. M., Drey, N., & Halcomb, E. (2022). The impact of interprofessional education on collaboration and patient outcomes in chronic disease care. Nurse Education Today, 117, 105492.

Huang, K., Lin, S., & Cheng, C. (2020). Personalized health education for chronic patients: A framework for practice. Patient Education and Counseling, 103(4), 730–737.

Lindblad, A. J. (2021). Ethical principles in chronic care coordination. Canadian Pharmacists Journal, 154(2), 65–67.

Morgan, D. J., Brownlee, S., Leppin, A. L., et al. (2020). Setting benchmarks for chronic disease care outcomes. BMJ Quality & Safety, 29(1), 74–79.

Nall, S., Kuperstein, J., & Song, J. (2020). Interdisciplinary care in chronic illness reduces hospital readmissions. Journal of Healthcare Quality, 42(4), 216–222.

Pascucci, D., Lee, M., & Procter, N. (2020). Improving chronic illness care through interprofessional collaboration. International Journal of Integrated Care, 20(3), 1–10.

Rawlinson, C., Carron, T., & Arditi, C. (2021). Barriers to team-based healthcare: A realist synthesis. Health Services Research, 56(2), 178–186.

Sibbald, S., McPherson, C., & Kothari, A. (2020). The role of teamwork in chronic care management. Healthcare Policy, 15(3), 71–85.

Tzenios, N. (2023). Health literacy strategies for patients with chronic illnesses. Health Education Research, 38(1), 89–97.

NURS FPX 6614 Assessment 2 Enhancing Performance as Collaborators in Care

Weiner, B. J., Alexander, J. A., & Shortell, S. M. (2020). Roles and structures in collaborative healthcare teams. Medical Care Research and Review, 77(5), 436–457.