Care Coordination and Discharge Planning Models
COMPETENCIES
7070.18.1 : Incorporating Cultural Awareness
The graduate develops a plan to incorporate cultural awareness in a healthcare setting
7070.18.2 : Applying Treatment Planning Methods
The graduate applies patient-centered treatment planning methods using evidence-based practice (EBP).
7070.18.3 : Applying Intervention Techniques
The graduate applies intervention techniques using evidence-based research in a healthcare setting.
7070.18.4 : Current Care Delivery
The graduate implements care delivery models, based on sociopolitical drivers, with current financial models and regulations in a variety of healthcare settings.
7070.18.5 : Digital Technologies and Patient Care
The graduate proposes way in which digital technologies may be used for compliance, patient care, and data security.
7070.18.6 : Community Relationships
The graduate explains the importance of developing and maintaining community relationships with the strategic partners across the healthcare continuum.
7070.18.7 : Mitigating Risk and Managing Chronic Illness and End-of-Life Care
The graduate creates strategies to mitigate risk and manage chronic illness and end-of-life care in various healthcare settings.
INTRODUCTION
In this course, we have examined models of healthcare in the United States and how emerging trends created by social and political drivers are transitioning these models from fragmented systems with unsustainable costs, suboptimal outcomes, and disparities in care to cohesive systems focused on quality-centered patient systems. A transition to greater coordination of care across providers and settings to improve quality of care and patient outcomes, as well as reduce spending—especially as it attributes to unnecessary emergency room utilization and repeated and unnecessary hospitalizations—is essential. This transformation of care must provide seamless, affordable, and quality care and focus on disparities, disease-type demographics, and chronic health conditions.
Health service coordinators (HSCs) are positioned to contribute to and lead the transformative changes that are occurring in healthcare by being a fully contributing member of the interprofessional team. These shifts require a new or enhanced set of knowledge, skills, and attributes that center around wellness and population care across the continuum.
The ability to engage in evidence-based practices (EBPs) in the application of patient-centered treatment planning methods is imperative. The HSC must be able to identify appropriate EBPs, as well as choose and appropriately implement methods based upon specific patient needs, all while maintaining a focus on the provision of quality, patient-centered care across the continuum of healthcare and throughout the disease process. A significant role of the HSC is discharge planning. Connecting patients with appropriate resources—both internally across disciplines and externally across the healthcare continuum—is essential to make the transition to improved quality of care and patient outcomes while reducing cost. Developing and maintaining relationships with community stakeholders to secure patient compliance and optimal patient outcomes is also an important aspect of the HSC’s role.
For this task, you are required to outline the components of a discharge plan for a patient that has been admitted to the hospital with complications of congestive heart failure. The patient is expected to be discharged back home. The discharge plans must be based on evidence-based practice, be multi-disciplinary, and depict a continuum of care.
SCENARIO
A 70-year-old male patient has been admitted to the hospital with complications of stage 4 congestive heart failure and is anticipated to be discharged in two days.
The life expectancy of this patient is less than six months. The patient is in denial about his diagnosis and is resistant to discuss additional resources in the home setting. The patient does not currently have a living will. The patient and spouse travelled 100 miles to the hospital; their home community is considered a healthcare professional shortage area. Patient’s support systems include a spouse and two children who live locally. The patient requires oxygen and a walker to ambulate. The patient’s spouse has reported that the patient is anxious about hospital bills and finances moving forward. Both the patient and the patient’s spouse’s primary language is Spanish, and their understanding of the English language is minimal. The patient has been hospitalized for management of congestive heart failure three times in the past 12 months. The patient’s insurance is Medicare.
REQUIREMENTS
Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. The originality report that is provided when you submit your task can be used as a guide.
You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.
A. Research evidence-based practices regarding the patient’s chronic illness to complete the following:
1. Provide an annotated bibliography with at least three sources.
2. Explain how each source from A1 could support a patient-centered discharge plan for this patient.
B. Based on current models of care delivery, explain which care delivery model would be most beneficial for this patient.
1. Summarize a healthcare regulation that influences the discharge plan for this patient.
2. Describe ways Medicare funding and current trends in Medicare reimbursement may affect care delivery for this patient.
C. Identify a digital technology that may be used for regulatory or patient compliance, patient care, or data security.
1. Explain how the identified digital technology could be integrated into the discharge plan to improve the patient’s outcome.
2. Discuss ways the identified digital technology could mitigate risk of readmission for the patient.
D. Outline the major elements of the patient/family-centered discharge plan by doing the following:
1. Identify essential strategic partners and organizational stakeholders who should participate in creating the discharge plan.
2. Identify any individualized interventions needed to meet the patient’s specific needs, based on the patient’s chronic illness.
3. Discuss the most appropriate engagement technique to motivate the patient’s continuous adherence to the discharge plan.
4. Compile a list of resources across the healthcare continuum and explain how the resources will assist this patient in managing the chronic illness and possible end-of-life care.
E. Discuss two examples of interventions in the discharge plan that are a result of the patient's culture.
1. Explain how the patient and patient’s family’s understanding of the discharge plan could impact the risk of hospital readmission.
2. Discuss how current trends in cultural awareness affect the discharge planning for the patient.
F. Reflect on the evolution of healthcare trends and how current delivery models have improved discharge planning and patient outcomes.
1. Reflect on the importance of developing and maintaining community relationships with the strategic partners across the healthcare continuum.
G. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.
H. Demonstrate professional communication in the content and presentation of your submission.
Care Coordination and Discharge Planning Models
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Institutional Affiliation
Date
Care Coordination and Discharge Planning Models
Annotated bibliography
Li, M., Li, Y., Meng, Q., Li, Y., Tian, X., Liu, R., & Fang, J. (2021). Effects of nurse-led transitional care interventions for patients with heart failure on healthcare utilization: A meta-analysis of randomized controlled trials. PloS One, 16(12), e0261300.
The researchers note that heart failure imposes a substantial burden on the patients and the healthcare system. As a result, there is a need to consider interventions to lessen the burden. The research objective is to test the effectiveness of the patient-centered care transitions for patients admitted for heart failure. The investigators searched for health-related databases published from January 2000 to June 2020. They included randomized controlled trials comparing nurse-led interventions with usual care for adults hospitalized with heart failure. The results demonstrated that nurse-led transitional care interventions decreased heart failure readmission risks and minimized hospital stay length. The article supports a patient-centered discharge plan for this patient since it advocates the need for nurses to spearhead efforts toward ensuring smooth transitional care. In this case, the nurses need to put the necessary interventions in the discharge plan. The move would reduce readmission and also reduce the admission period.
Gane, E. M., Schoeb, V., Cornwell, P., Cooray, C. R., Cowie, B., & Comans, T. A. (2022, February). Discharge Planning of Older Persons from Hospital: Comparison of Observed Practice to Recommended Best Practice. In Healthcare (Vol. 10, No. 2, p. 202). Multidisciplinary Digital Publishing Institute.
In this research paper, the authors examined the discharge planning of two Australian hospitals and compared them to best practice recommendations. The results demonstrated that the two facilities employed communication, collaboration, coordination, and patient/family engagement in discharge planning. There were also clear responsibilities and goals in the healthcare team. As a result, the patient readmission rate for older adults was lower because of the interventions used. The research is critical in planning discharge for this particular patient because it emphasizes the need for professionals to work together. Through collaboration, the provider will improve the health outcome of the patient. The research also shows the importance of involving patients and family members in the discharge plan process.
Säfström, E., Jaarsma, T., & Strömberg, A. (2018). Continuity and utilization of health and community care in elderly patients with heart failure before and after hospitalization. BMC geriatrics, 18(1), 1-9.
The article acknowledges that the transition from home to hospital is usually problematic because of insufficient care coordination. The researchers undertook a cross-sectional study with patients with heart failure. They collect data using phone interviews and medical charts. The results demonstrated that while most of the patients got written information on discharge, a third of them lacked knowledge about who to contact if their case deteriorated after discharge. The paper is critical for this patient because it emphasizes the need to ensure that patients understand more about the discharge plan. The patient needs to understand who to contact if his case deteriorates after the discharge.
Care delivery models
Since the patient has multiple challenges, a team nursing model would be the most appropriate. The team nursing model entails where a group of professional and non-professional nursing personnel collaborate to identify, plan and implement client-centered care. The team usually has a charge nurse or team leader tasked with assigning patients to the team members. The leader is knowledgeable about the patients and their respective plans of care. A team nursing model is applicable for the patient since each team member will bring something important. The different strengths of the healthcare professionals will be utilized to provide the best care possible (Beckett et al., 2021). Additionally, the patient will receive individualized care, which will improve his outcomes and satisfaction. Since the model will bring different professionals together, it will allow each team member to undertake functions that which they excel, ensuring that the patient gets the highest quality of care possible. Because of the involvement of diverse healthcare professionals, the patient will receive comprehensive care (Beckett et al., 2021). Moreover, more than one healthcare professional will contribute to the decision-making process. In this case, the patient has less than six months of life expectancy and continues to deny his diagnosis. Dealing with the patient will require different professionals to join hands and make the most appropriate decision for the client.
Regulatory requirements guide the discharge of the patient. Firstly, receiving oral and written notice of a proposed discharge is critical. The client and family need to be aware of the discharge to decide if it is the right thing to do. Medicare-participating healthcare facilities must deliver the valid written notice to their clients. The notice aims to explain the patient’s rights, including discharge appeal rights. While undertaking the discharge, hospitals should involve the patients and carers. The move is essential in managing patient or carer expectations and understanding the complexes involved. Involving the patient and carers is a challenging process and may necessitate meetings. Planning the discharge should take place for not less than seven days. The major aim here is to ensure that all the necessary parties are involved. For instance, the patient is an older adult with a chronic condition. Before discharging him, the hospital must ensure that all the individuals involved in his care are engaged so that the discharge is as smooth as possible.
The patient can only qualify for hospice if he has Medicare Part A and meets the following conditions. Firstly, the hospice doctor should certify that the patient is terminally ill and has a life expectancy of fewer than six months (Harris et al., 2014). In this case, the doctor has established that the patient has a life expectancy of less than six months since he has complications of stage 4 congestive heart failure. Secondly, the patient must accept comfort care, instead of care to cure an illness. The problem here is that the patient is in denial about his diagnosis and is resistant to discussing additional resources in the home setting. This may make it challenging for Medicare to cater to the patient. Thirdly, the patient is supposed to sign a statement choosing hospice rather than other Medicare-covered treatments (Harris et al., 2014). Since the patient is in denial of the diagnosis, he may be reluctant to sign such a statement, which would limit his access to care. However, Medicare will not cover the following once hospice benefits commence. Firstly, it will not cover any treatment intended to cure the terminal illness. The patient has a right to stop the hospice care at any time. Secondly, Medicare will not pay for a prescription to cure the illness. It will pay for medication aimed at controlling pain and symptoms. Thirdly, any care from a hospice provider that was not set up by the hospice medical team will not be covered. Additionally, Medicare will not cover room and board for hospice care at home or in a nursing home.
Digital Technologies and Patient Care
The identified technology is telemedicine. Technology entails using technology to provide care at a distance. A physician in a particular location will use telecommunications infrastructure to deliver care to a client at a distinct site (Jnr, 2020). Here, healthcare professionals can evaluate, diagnose and treat patients in remote locations. The approach has been a revolution in the last decade, and it is becoming an increasingly important part of the American healthcare infrastructure. The approach is critical because physicians can offer services without their clients visiting the clinic.
In this case, the patient lives 100 miles from the hospital. In addition, the patient stays in a place that is considered to be a healthcare professional shortage area. The use of telemedicine is appropriate for the patient since he may not receive much care in his location because of the shortage of healthcare professionals. The discharge plan can involve specific days when a physician, nurse, or other healthcare professional can contact the patient or family and monitor progress. A nurse can ensure that the patient takes his medication as required. The nurse can check the client's kind of diet as required in the discharge plan. If the client needs any assistance, a healthcare professional can advise accordingly.
The use of telemedicine can mitigate the risk of readmission for the patient in various ways. Firstly, it can enhance the patient’s understanding of post-discharge instructions. Sometimes, patients do not understand post-discharge instructions given by the physician (Sheikh et al., 2018). The gaps in post-discharge care are major because of poor health literacy. Using telemedicine, a healthcare professional can assist the patient and family understand the instructions. Where the client does not understand, the healthcare professional can clarify, preventing the patient from making errors that can necessitate readmission. Secondly, telemedicine can assist in automating medication reminders. The patient is in denial of the diagnosis and may not comply with the medication provided (O’Connor et al., 2016). However, reminders can improve medication-taking behavior as the healthcare providers become more proactive in the process. The provider can establish processes like alerts when medications are overdue. Furthermore, telemedicine will be critical in addressing issues without the client visiting the facility. Instead of coming to the facility when an issue arises, healthcare providers can attend to the client remotely. As a result, this will reduce the chances of the client visiting the facility for readmission since most of the issues arising can be addressed in real-time. Additionally, telemedicine will provide follow-up appointments when the patient is most comfortable (Reed et al., 2021). The move reduces strain on the part of the patie...