Comprehensive Needs Assessment

Comprehensive need assessment is essential to help healthcare professionals in using different resources that will help them to enhance patient care. This assessment is designed to get knowledge about the gaps that can come up in patient care and how to overcome those gaps through care coordination. This assessment also helps to identify patients ‘needs and the method to assess patients’ needs. Moreover, care coordination is essential for patient care, and here we will discuss different strategies that will enhance patient care. Also, this assessment is designed to discuss interdisciplinary team collaboration toward care coordination. 

Current Gaps in the Patient’s Care

79 years old diabetic patient named Mr. Decker comes up in the hospital with the issue of an infected toe, but his failure to follow post-discharge guidelines has led to his readmission with a serious infection. Various factors or gaps come up in patient care that patient Mr. Decker belongs to a low-income family, so he cannot afford costly treatment, but the healthcare provider did not notice this element. Secondly, the healthcare provider did not give complete knowledge regarding the post-discharge healthcare routine, and due to this, the patient’s health condition became critical. Gaps also come up because healthcare providers do not evaluate patient conditions after discharge. 

The Patient-Centered Assessment Method was used as the needs evaluation tool to ensure Mr. Decker’s physiological, social, religious, and psychological requirements were fulfilled (Perazzo et al., 2020). The tool was chosen because it emphasizes an effort-based approach. This approach will help healthcare professionals to provide patients with extensive care by paying attention to their emotional needs. 

NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment

Informational Needs for Patient’s Optimal Care

The information about the patient that is needed to access the current level of care is 

• Patient (Mr. Decker) medical records like age, weight, and patient allergic condition are needed. 
• Patient’s emotional behavior, desire, medical schedule, and religious beliefs will help to evaluate whether the patient’s needs are fulfilled.  

Strategy for Gathering Additional Necessary Data

The preliminary discussion will help to understand Mr. Decker’s condition; thus, healthcare professionals must focus on obtaining additional information from the patient’s family (Mertens et al., 2020). It is essential to interview those familiar with him to get extra details about his behavior, interests, diet, and other factors important for optimal care. Interviewing his spouse and kids, who are the ones who know him well, is therefore advised. Furthermore, because he belongs to an older age group, it is unclear that he uses social media, but it is still advisable to examine it. Interviewing his friends will also help the healthcare staff better understand his hobbies and routines.

Electronic health record assists by providing prior health history and treatment from a previous healthcare worker. To maintain HIPAA compliance and protect patient data, it is important to be honest and get the patient’s approval before using his data (Shah & Khan, 2020). Documents for patient registration and routine follow-up can also be used to collect data frequently. Systems for exchanging health records of patients are set up to obtain Mr. Decker’s longitudinal medical data from multiple healthcare professionals to clarify the diverse effects of his condition, such as diabetes and aging. These strategies reflect a holistic, coordinated care perspective as these strategies will help to gather in-depth knowledge about the patient’s medical record so that patient care can be enhanced (Mertens et al., 2020). 

Societal, Economic, and Interdisciplinary Factors Affecting Patient Care

Factors affecting patient care include financial crisis, aging, and less social support. One of the concerning factors includes aging as the patient is 79 years old and can suffer from various issues like weight loss, weak bones, less appetite, vision or hearing issues, and much more. So it becomes quite difficult to know the reason behind serious infection as the patient’s immune system weakens with age. So aging is one of the risk factors that can cause severe complications in chronic patients (diabetic) (Liu et al., 2019). 

Mr. Decker’s income is the key economic determinant influencing his health outcomes because he comes from a low-income family and relies on Medical insurance to receive his medical treatment (Palileo-Villanueva et al., 2022). The insurance organization will bear hospitalization costs but does not cover other connected expenses, such as services for different therapies. As a result, even though recovery services are the recommended therapy for Mr. Decker’s illness, he cannot pay for them. With increasing costs for other premium packages, the 2019 estimated costs for Medicare remain at 437$ as the monthly premium for the hospital insurance policy and 135.50$ for the medical coverage plan. The type of insurance plan Mr. Decker could afford changed due to his poor financial situation, which also altered the quality of his medical care (Palileo-Villanueva et al., 2022).

Another factor behind the patient’s condition is less social support, as his family members, like his daughter and wife, will not visit the hospital daily, so he has little emotional support. Due to less social support, post-discharge procedures cannot be carried out. According to research, social support is essential for elderly patients’ health outcomes, and older individuals who lack it are more likely to experience serious complications (Ko et al., 2019). All these factors will potentially affect patient outcomes as the patient did not get social support, and his age can also be the risk for serious infection (Milgrom et al., 2019). 

Professional Standards Influence on Patient Care and Care Coordination Outcomes 

The patient care coordination can be boosted by scrutinizing requirements and demands of patient. One of the credible organizations designed in 2017, named the National Quality Forum, provides standards for safety and care coordination outcomes (Namburi & Lee, 2022). This credible organization aims to enhance patient safety and quality of care (Namburi & Lee, 2022). The Care Coordination and Transition Management Logic Model provides effective benchmark standards to measure the effectiveness of care coordination towards patients (Hofmann & Erben. J, 2020). The justification behind this model is that this model provides holistic relation between nurses’ competencies, care coordination, and patient quality outcomes. This model also encourages healthcare professionals to focus on patient-centered care. With the help of this model, the healthcare professional’s performance can be measured as it provides various standards like the organization’s need to focus on patients’ desires, error-free treatment, evidence-based practice, and ongoing care coordination plan updates (Hofmann & Erben. J, 2020).

NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment

The Agency for Healthcare Research and Quality (AHRQ) developed the care coordination evaluation benchmark standards (Artiga et al., 2020). The aim of this agency is to enhance care coordination by providing different methods (such as communication, collaboration through electronic media, routine checkups, and self-care management, etc.), and finally assess the results by interviewing the patient, the patient’s family, medical staff, and other stakeholders. This model is recommended because it is easy to execute, specifies objectives and desired results, and necessitates an interdisciplinary method to gather viewpoints. Additionally, it encourages communication among various healthcare experts and is a patient-centered practice (Artiga et al., 2020).

Evidence-Based Practices for Successful Implementation of Patient Care Coordination

An evidence-based strategy can offer tried-and-true methods of care for managing elderly patients with infection. One of these is GENESIS (Generalized Early Sepsis Intervention Strategies), which focuses on recognizing infection outbreaks, determining the occurrence of infection, and determining the fatality rates associated with sepsis. GENESIS successfully mitigated the death rate by 14% (Kregel et al., 2022).

Another tactic is routine evaluation of older patients, which is strongly advised for individuals with diabetes or high blood pressure. Continuous monitoring of the patient’s essential signs, including heart rate, white cells count, and temperature checkup, can help identify sepsis early. Nursing procedures for geriatric individuals with risk indicators include hourly vital sign checks, structural input and output monitoring, and determining changing levels of perception (LeRoith et al., 2019). 

Another approach is to use the sepsis six bundles, a collection of medical interventions that can reduce the likelihood of death after a person has been diagnosed with the illness. Sepsis six comprises monitoring urine production, titration of oxygen level by 94%, blood sample collection, administration of antibiotics, glucose monitoring, and initiation of intravenous fluid therapy. All of this must be completed within an hour of the assessment (Bleakley & Cole, 2020).

Benefits of Multidisciplinary Approach to Patient Care

In healthcare, a multidisciplinary approach often enhances patient care. This is because numerous healthcare providers can recognize and effectively manage a patient’s multiple concerns and enhance patient care simultaneously. This method, for instance, might have benefited Mr. Decker earlier because it would have taken into account his age and diabetes, which would have resulted in a better treatment plan for him. The multidisciplinary team for treatment of Mr. Decker must comprise of nurse with elderly care experience, psychologist and social worker to find best intervention plan. Additionally, by assigning tasks, this method simplifies operations and reduces errors. The main cause of these medication error was not keep account of age and circumstances related to socioeconomics. This deterioration of health can be prevented by early adapting multidisciplinary team, that could have kept all the variables in check. The gaps in Mr. Decker’s care identified due to social, economic, and interprofessional variables can be minimized using an interdisciplinary strategy. According to the research, a multidisciplinary strategy can decrease readmissions by 13% by giving the patient more thorough care (Ni et al., 2019).

NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment

Conclusion

Care Coordination will help to enhance the overall quality of care toward patients. Various gaps will occur in providing quality care to Mr. Decker. To identify those gaps, a comprehensive need assessment is needed as it will help to give better solutions to resolve them. Moreover, several aspects of patient care are outlined, and evidence-based strategies are designed to enhance patient care. Furthermore, multidisciplinary collaboration will help identify gaps and enhance patient safety. 

References

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Bleakley, G., & Cole, M. (2020). Recognition and management of sepsis: The nurse’s role. British Journal of Nursing, 29(21), 1248–1251. https://doi.org/10.12968/bjon.2020.29.21.1248

Hofmann, F., & Erben, M. J. (2020). Organizational transition management of circular business model innovations. Business Strategy and the Environment, 29(6), 2770–2788. https://doi.org/10.1002/bse.2542

Ko, H., Park, Y.-H., Cho, B., Lim, K.-C., Chang, S. J., Yi, Y. M., Noh, E.-Y., & Ryu, S.-I. (2019). Gender differences in health status, quality of life, and community service needs of older adults living alone. Archives of Gerontology and Geriatrics, 83, 239–245. https://doi.org/10.1016/j.archger.2019.05.009

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Liu, X., Xu, Y., An, M., & Zeng, Q. (2019). The risk factors for diabetic peripheral neuropathy: A meta-analysis. Plos one, 14(2), 0212574. https://doi.org/10.1371/journal.pone.0212574

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Milgrom, J., Hirshler, Y., Reece, J., Holt, C., & Gemmill, A. W. (2019). Social support—A protective factor for depressed perinatal women? International Journal of Environmental Research and Public Health, 16(8). https://doi.org/10.3390/ijerph16081426

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Ni, Y., Liu, S., Li, J., Dong, T., Tao, L., Yuan, L., & Yang, M. (2019). The effects of nurse-led multidisciplinary team management on glycosylated hemoglobin, quality of life, hospitalization, and help-seeking behavior of people with diabetes mellitus. Journal of Diabetes Research, 2019, 1–9. https://doi.org/10.1155/2019/9325146

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Perazzo, M. F., Serra-Negra, J. M., Firmino, R. T., Pordeus, I. A., Júnior, P. A.M., & Paiva, S. M. (2020). Patient-centered assessments: How can they be used in dental clinical trials? Brazilian Oral Research, 34(2). https://doi.org/10.1590/1807-3107bor-2020.vol34.0075

Shah, S. M., & Khan, R. A. (2020). Secondary use of electronic health record: Opportunities and challenges. IEEE Access, 1–1. https://doi.org/10.1109/access.2020.3011099