Patient Discharge Care Planning

This assessment discusses the discharge care planning of Marta Rodriguez. She was recently moved to the hospital after a fatal accident that she faced while going to college. She spent four weeks in the trauma center, survived multiple surgeries, and was treated with antibiotics. For the given discharge planning of Marta, I am playing the role of senior care coordinator, and I am going to present the case of Marta in the upcoming meeting to discuss the discharge plans with the interdisciplinary team members.

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Longitudinal, Patient-Centered Care Plan

In order to provide Marta Rodriguez with longitudinal, patient-centered care, the interdisciplinary team will use HIT components to enhance communication and care coordination across the continuum of care. HIT elements such as electronic health records (EHRs), secure messaging platforms, telehealth technology, and medication reconciliation tools will be used by team members. EHRs will enable the team to access and update Marta’s medical records in real-time, which will help develop a comprehensive care plan for her (Schwab et al., 2021). Secure messaging platforms will facilitate communication among team members, especially regarding changes in Marta’s condition, appointments, and medication schedules (Flickinger et al., 2022). Telehealth technology will enable remote monitoring of Marta’s vital signs, allowing the team to identify potential complications and intervene promptly (Chowdhury et al., 2020). Finally, medication reconciliation tools will ensure accurate medication lists, minimizing medication errors.

To prevent readmission of Marta 48 hours after being discharged, the interprofessional team will need to ensure that Marta receives appropriate education, support, and follow-up care (Oksholm et al., 2023). The HIT elements can support this effort. For example, the team can use telehealth technology to monitor Marta’s progress post-discharge, provide virtual support, and detect any issues that may lead to readmission. Additionally, secure messaging platforms can provide Marta with timely and accurate information about her medication and follow-up appointments.

Meanwhile, using these HIT elements will support the coordination of care for Marta by promoting communication and collaboration among team members. Team members can access the same information about Marta, allowing them to develop a comprehensive care plan for her. Additionally, using EHRs will enable team members to track Marta’s progress over time, ensuring that she receives the appropriate care at every stage of her recovery. By using HIT elements, the interprofessional team can provide Marta with a patient-centered, coordinated, and effective care plan that meets her unique needs.

Data Reporting

Reporting data is extremely important in the healthcare industry since it helps shape care coordination and administration, as well as clinical efficiency and interdisciplinary innovation in treatment. In the case of Marta Rodriguez, data reporting specific to her behaviors can be leveraged to improve the quality of her care and support her recovery. There are at least three ways in which data reporting can shape these aspects of care:

1. Care coordination: Data reporting can facilitate care coordination among interprofessional team members by providing a shared understanding of Marta’s condition and progress (Brooks et al., 2020). For example, data on Marta’s medication adherence, vital signs, and symptoms can be reported to the team through EHRs or other secure messaging platforms, enabling them to collaborate effectively in managing her care. This can lead to more effective and efficient care, reducing the risk of complications or readmissions.
2. Care management: Data reporting can also shape care management by identifying areas where Marta may need additional support or interventions. For example, data on her pain levels, mobility, and nutritional status can be reported to the team, enabling them to adjust her care plan as needed. This can improve the quality of her care and enhance her recovery process.
3. Interprofessional innovation: Data reporting can also drive innovation in interprofessional care by providing insights into Marta’s behaviors and preferences. For example, data on her language preferences or cultural background can be reported to the team, enabling them to tailor their care to meet her needs. This can lead to more patient-centered care and better outcomes.

To evaluate the quality of the data, the team should ensure that it is accurate, complete, and timely. This can be done by implementing data validation protocols, conducting regular audits, and training team members on data entry and reporting best practices. Additionally, the team should ensure that the data is relevant to Marta’s care goals and aligns with evidence-based practices. The team can make informed decisions using high-quality data and provide Marta with the best possible care.

Client’s Record Influencing Health Outcomes

When it comes to improving health outcomes, data collected from patient records is invaluable. The case of Marta Rodriguez illustrates how interprofessional teams can use health information technology (HIT) to collect, analyze, and share information from client records to improve patient care and outcomes. In this regard, we will explore how information obtained from patient records can be used to favorably influence health outcomes, as well as how members of interprofessional teams can coordinate their results in the context of the collaborative use of health information technology (HIT).

HIT can help interprofessional teams collect and analyze data from client records, which can be used to identify trends, patterns, and gaps in care (Leslie & Paradis, 2018). For instance, data collected from Marta’s records can provide insight into her medical history, medication regimen, and health status, enabling the team to develop a comprehensive care plan that addresses her unique needs. HIT can also help to identify potential risks, such as adverse drug reactions or postoperative complications, which can be addressed promptly to prevent negative health outcomes.

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Additionally, using HIT can facilitate care coordination between interprofessional team members. By sharing information from client records, team members can collaborate more effectively in managing patient care. HIT tools such as EHRs and secure messaging platforms enable team members to communicate in real time, ensuring that all members are current on the latest patient information. This can reduce the risk of miscommunication and errors, leading to better health outcomes for the patient.

To effectively coordinate their findings, interprofessional team members must collaborate to develop a shared understanding of the patient’s care needs. This requires clear communication, a shared vision of the care plan, and a willingness to work together to achieve common goals (Rawlinson et al., 2021). HIT tools can support this collaborative approach by providing a centralized platform for team members to access and share information. This can ensure that all members have a complete picture of the patient’s care needs, enabling them to work together to provide holistic care that addresses all aspects of their health.

Positive health outcomes can be influenced by the use of HIT to gather, analyze, and distribute data from patient records. Interprofessional teams can use HIT tools to coordinate their findings, ensuring all members can access the latest patient information. By working collaboratively and using HIT tools effectively, interprofessional teams can provide patient-centered care that addresses all aspects of the patient’s health, leading to better health outcomes.

Conclusion

Marta Rodriguez’s care after discharge involves a patient-centered approach with coordinated and effective care. The team will utilize HIT elements such as EHRs, telehealth technology, medication reconciliation tools, and secure messaging platforms to enhance communication and coordination across the care continuum. Staff members understand that data reporting significantly influences care coordination, clinical efficiency, and interprofessional innovation. The team can gain valuable insights into Marta’s behaviors and preferences with high-quality data, leading to better patient-centered care and outcomes. Client records are a valuable source of data for improving health outcomes. In this regard, HIT can help interprofessional teams collect, analyze, and share this information to develop a comprehensive care plan tailored to Marta’s unique needs. The interprofessional team’s effective collaboration will ensure that Marta receives a proper education, support, and follow-up care, reducing the risk of readmission within 48 hours after discharge.

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

References

Brooks, E. M., Winship, J. M., & Kuzel, A. J. (2020). A “Behind-the-Scenes” look at interprofessional care coordination: How person-centered care in safety-net health system complex care clinics produce better outcomes. International Journal of Integrated Care, 20(2). https://doi.org/10.5334/ijic.4734 

Chowdhury, D., Hope, K. D., Arthur, L. C., Weinberger, S. M., Ronai, C., Johnson, J. N., & Snyder, C. S. (2020). Telehealth for pediatric cardiology practitioners in the time of COVID-19. Pediatric Cardiology, 41(6), 1081–1091. https://doi.org/10.1007/s00246-020-02411-1 

Flickinger, T. E., Waselewski, M., Tabackman, A., Huynh, J., Hodges, J., Otero, K., Schorling, K., Ingersoll, K., Tiouririne, N. A.-D., & Dillingham, R. (2022). Communication between patients, peers, and care providers through a mobile health intervention supporting medication-assisted treatment for opioid use disorder. Patient Education and Counseling. https://doi.org/10.1016/j.pec.2022.02.014 

Leslie, M., & Paradis, E. (2018). Is health information technology improving interprofessional care team communications? An ethnographic study in critical care. Journal of Interprofessional Education & Practice, 10, 1–5. https://doi.org/10.1016/j.xjep.2017.10.002 

Oksholm, T., Gissum, K. R., Hunskår, I., Augestad, M. T., Kyte, K., Stensletten, K., Drageset, S., Aarstad, A. K. H., & Ellingsen, S. (2023). The effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospital to home health care—A systematic review. Journal of Advanced Nursing. https://doi.org/10.1111/jan.15579 

Rawlinson, C., Carron, T., Cohidon, C., Arditi, C., Hong, Q. N., Pluye, P., Peytremann-Bridevaux, I., & Gilles, I. (2021). An overview of reviews on interprofessional collaboration in primary care: Barriers and facilitators. International Journal of Integrated Care, 21(2), 32. https://doi.org/10.5334/ijic.5589 

Schwab, P., Mehrjou, A., Parbhoo, S., Celi, L. A., Hetzel, J., Hofer, M., Schölkopf, B., & Bauer, S. (2021). Real-time prediction of COVID-19 related mortality using electronic health records. Nature Communications, 12(1). https://doi.org/10.1038/s41467-020-20816-7 

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