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Assessment 1: Comprehensive Needs Assessment

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Capella University

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NURS-FPX 6610 Introduction to Care Coordination

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MAR 24, 2024
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Thorough Assessment of Patient Needs
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Executing a comprehensive evaluation of patient needs mandates healthcare
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practitioners to employ a variety of resources aimed at enhancing patient well-being.
This evaluation serves to pinpoint and rectify deficiencies in patient care through
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efficient coordination. It also aids in identifying patients' needs and devising strategies to
evaluate and fulfill them. Emphasizing the significance of care coordination in patient
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well-being, this evaluation explores different methods to bolster patient care.

Furthermore, it investigates the role of interdisciplinary team collaboration in care
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coordination.

Current Deficiencies in Patient Care

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An illustrative case study featuring a 79-year-old diabetic individual named Mr. Decker
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highlights existing deficiencies in patient care. Factors such as Mr. Decker's limited
financial means, inadequate communication regarding post-discharge care, and
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absence of post-discharge assessment contribute to gaps in his care. Employing the

Patient-Centered Assessment Method, the assessment tool underscores an
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activity-oriented approach to tackle not only Mr. Decker's physiological needs but also
his social, spiritual, and emotional requirements.
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Informational Requirements for Optimal Patient Care

To evaluate the present level of care, essential patient data encompasses medical
records (e.g., age, body mass, allergies), emotional demeanor, preferences, medical
regimen, and religious convictions. Acquiring additional pertinent information entails
conducting initial conversations and consulting Mr. Decker's relatives, taking into
account aspects such as his preferences, dietary habits, and social interactions.
Electronic health records, patient registration forms, and regular follow-up protocols are
also utilized, ensuring compliance with HIPAA regulations.

Societal, Economic, and Interdisciplinary Factors Influencing Patient Care

Elements such as economic downturns, aging, and inadequate social backing

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significantly influence patient well-being. Aging, particularly, poses additional risks for
complications in chronic patients like Mr. Decker. Economic factors, such as Mr.

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Decker's low income, impede his access to recommended treatments. Scarce familial
support further complicates post-discharge procedures, potentially resulting in severe
complications.

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Professional Standards and Care Coordination Outcomes

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Organizations like the National Quality Forum and the Agency for Healthcare Research
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and Quality play pivotal roles in establishing benchmarks for safety, care coordination
outcomes, and assessment criteria. Models such as the Care Coordination and
Transition Management Logic Model, along with evidence-based practices, contribute to
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efficient care coordination, with a focus on patient-centric care and interdisciplinary

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cooperation.

Evidence-Based Practices for Coordinating Patient Care

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Evidence-backed strategies like GENESIS, routine assessment of elderly patients, and

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the sepsis six bundles are advocated for managing elderly patients with infections.
These practices aim to identify and tackle infection outbreaks, monitor vital signs, and
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deliver timely interventions to mitigate mortality rates associated with sepsis.

Advantages of a Multidisciplinary Approach to Patient Care

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A multidisciplinary approach in healthcare enhances patient well-being by concurrently

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considering various facets of a patient's health. This approach minimizes errors,

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particularly those stemming from socioeconomic and age-related factors. The care gaps

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observed in Mr. Decker's case, influenced by social, economic, and interdisciplinary
factors, could have been alleviated through a multidisciplinary team. Research indicates
that a multidisciplinary approach can curtail readmissions and offer more
comprehensive care to patients.

Conclusion

In conclusion, care coordination is pivotal for augmenting the overall quality of patient
care. Identifying and rectifying deficiencies in patient care, particularly those influenced
by socioeconomic, age-related, and interdisciplinary factors, necessitates a
comprehensive evaluation of needs. This evaluation, coupled with evidence-based
practices and adherence to professional standards, contributes to enhanced patient

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care. The integration of a multidisciplinary approach further fortifies patient care
outcomes.

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References

Artiga, S., Orgera, K., & Pham, O. (2020). Issue brief disparities in health and health

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care: Five key questions and answers. Deancare.com. [Link]

Bleakley, G., & Cole, M. (2020). Recognition and management of sepsis: The nurse’s
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role. British Journal of Nursing, 29(21), 1248–1251. [Link]
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Hofmann, F., & Erben, M. J. (2020). Organizational transition management of circular
business model innovations. Business Strategy and the Environment, 29(6),
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2770–2788. [Link]
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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
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of older adults living alone. Archives of Gerontology and Geriatrics, 83, 239–245. [Link]

Kregel, H. R., Murphy, P. B., Attia, M., Meyer, D. E., Morris, R. S., Onyema, E. C.,
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Adams, S. D., Wade, C. E., Harvin, J. A., Kao, L. S., & Puzio, T. J. (2022). The geriatric
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nutritional risk index as a predictor of complications in geriatric trauma patients. Journal

of Trauma and Acute Care Surgery, 93(2), 195–199. [Link]
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LeRoith, D., Biessels, G. J., Braithwaite, S. S., Casanueva, F. F., Draznin, B., Halter, J.
B., Hirsch, I. B., McDonnell, M. E., Molitch, M. E., Murad, M. H., & Sinclair, A. J. (2019).
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Treatment of diabetes in older adults: An endocrine society* clinical practice guideline.

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The Journal of Clinical Endocrinology & Metabolism, 104(5), 1520–1574. [Link]

Do you need Help to complete your Capella Uni MSN FlexPath Class in 1 Billing?
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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. [Link]

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