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Assessment 1: Defining a Gap in Practice

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Capella University

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NURS-FPX 6614 Structure and Process in Care Coordination

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MAR 24, 2024
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Proposing Evidence-Based Change Clinical Priorities
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and Information Gaps for the Elderly
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Senior citizens (65+) residing in metropolitan healthcare facilities with multiple
long-standing ailments necessitate a holistic, individual-centered strategy. This entails
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grasping their extensive requirements, encompassing medical as well as psychosocial

aspects. Seamless shifts between inpatient care and home-based assistance are critical
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to avert health complications and unnecessary hospital readmissions. Given their

intricate medication routines, effective medication management and adherence are
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indispensable. Educating both patients and caregivers enhances at-home care and
alleviates the strain on the healthcare system (Vareta et al., 2022). Nevertheless,
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obstacles persist. A significant challenge is the disparity in electronic health records

(EHR).
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Accurate, current EHRs are pivotal for efficient care coordination. Additionally,
communication discrepancies between primary and specialty care providers can result
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in ineffective care, such as duplicate testing or contradictory treatments. Furthermore,

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inadequately addressing the patient’s socioeconomic circumstances can adversely

affect health outcomes (Fjellså et al., 2022). Confronting these barriers is imperative for
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enhanced care coordination for this demographic.

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PICOT Question Related to Care Coordination Gap

The proposed PICOT question – “In senior citizens with multiple chronic conditions in
metropolitan healthcare settings (P), how does implementing a coordinated
interprofessional care plan (I) compared to standard care without active coordination (C)
influence the number of hospital readmissions (O) over 6 months (T)?” – arises from
evident shortcomings in current care models. Studies consistently demonstrate that
fragmented care, often typical of the standard model, correlates with increased hospital
readmission rates, decreased patient satisfaction, and a rise in preventable
complications for the elderly.

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For instance, a study revealed that senior citizens receiving uncoordinated care had a
50% higher likelihood of being readmitted to the hospital within 30 days of discharge

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(Hovsepian et al., 2023). Another study underscored that lack of care coordination for
elderly patients resulted in prolonged hospital stays and escalated healthcare costs by
approximately 30% (Wolff et al., 2023). Hence, a care coordination approach is deemed

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advantageous for this demographic.

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Evaluation of Potential Services and Resources for Care Coordination Senior
citizens with multiple chronic conditions in urban locales necessitate specialized care
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services and resources, such as geriatric assessment units, which offer comprehensive
evaluations encompassing medical, psychosocial, and functional health aspects.
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Comprising a multidisciplinary team, these units provide a holistic understanding of

patients’ health needs. Additionally, home care services, ranging from daily support to
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specialized nursing care, are crucial for these individuals, ensuring their autonomy (Liu
et al., 2023). Telehealth consultations, facilitated by technology, have also emerged as a
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beneficial tool, particularly for those facing mobility challenges.

However, several barriers impede optimal care coordination. Service fragmentation

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remains a significant challenge, often leading to miscommunications and inefficiencies.

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Limited health literacy complicates their comprehension of health information and

optimal care pathways. Financial constraints also pose a considerable barrier; despite
insurance coverage, the costs associated with various services can be prohibitive (Arain
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et al., 2022). It is imperative to adopt a patient-focused approach, leveraging scholarly

insights to refine care coordination, ensuring accessibility, and efficacy in serving this
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vulnerable demographic.
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Optimal Care Coordination Intervention To enhance evidence-based practice for
senior citizens in metropolitan healthcare settings, an Interprofessional Collaborative
Care Team (ICCT) is recommended. The ICCT, comprising physicians, nurses,
pharmacists, social workers, and patient navigators, would ensure comprehensive care
coordination (Gao et al., 2023). Key responsibilities of this team would include
consistent patient evaluations, formulation and revision of individualized care plans,
enlightening patients and caregivers through dedicated educational sessions, and
ensuring medication reconciliation to prevent potential drug interactions and enhance
medication compliance. By integrating these diverse professionals, the intervention
addresses the complex needs of the population in a streamlined and effective manner.

Nursing Diagnosis and Collaborative Care Approach The primary nursing diagnosis

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identified is the risk for ineffective health management. This risk stems from the
multifaceted nature of the health issues experienced by senior citizens and the
tendency for healthcare services to be fragmented, potentially causing care gaps.

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Regular nursing-led educational sessions will be initiated to counteract this risk, focused
on enhancing patient and caregiver understanding of health conditions and treatment

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modalities. Furthermore, prioritizing collaborative care meetings that incorporate the
voices of patients, caregivers, and the entire healthcare team can ensure cohesive care
planning and delivery. Additionally, the optimal utilization of Electronic Health Records
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(EHR) is a cornerstone strategy. It ensures that all care team members have real-time
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access to patient data, fostering effective communication and coordination (Innab,
2022).
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Structuring the Intervention and Anticipating Outcomes The initial phase entails the
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recruitment and meticulous training of dedicated ICCT members. Subsequently, clear

protocols for routine patient assessments and evaluations will be developed and
institutionalized. A robust system that facilitates seamless communication and ensures
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consistent EHR updates will also be implemented (Strachna et al., 2022). Through
these interventions, several measurable outcomes are projected. There’s an
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anticipation of a marked reduction in hospital readmissions by approximately 25% over

six months. Concurrently, feedback mechanisms like patient satisfaction surveys should
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reflect improved scores, particularly in areas of care coordination.

A pivotal metric would be observing a pronounced increase in medication compliance

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among our target population. This approach is predicated on several assumptions, such
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as unwavering commitment and active participation of all ICCT members, sustained

resource allocation and support from the overarching healthcare entity, and proactive
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engagement from patients and their caregivers throughout the care continuum. As this
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care coordination model is operationalized, it’s imperative to maintain a feedback loop
for regular assessment of the process, continuous professional development, and
invaluable insights to drive iterative refinements in the care process.

References

Arain, S., Al Shakori, M., Thorakkattil, S. A., Mohiuddin, S. I., & Al-Ghamdi, F. (2022).
Implementation of pharmacist-led telepsychiatry services: Challenges and opportunities
in the midst of COVID-19. Journal of Technology in Behavioral Science, 7, 468–476.
https://doi.org/10.1007/s41347-022-00266-2

Fjellså, H. M. H., Husebø, A. M. L., & Storm, M. (2022). eHealth in care coordination for
older adults living at home: Scoping review. Journal of Medical Internet Research,

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24(10), e39584. https://doi.org/10.2196/39584

Gao, H., Yous, M.-L., Connelly, D., Hung, L., Garnett, A., Hay, M., & Snobelen, N.

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(2023). Implementation and impacts of virtual team-based care planning for older
persons in formal care settings: A scoping review. DIGITAL HEALTH, 9,

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205520762311515. https://doi.org/10.1177/20552076231151567

Hovsepian, V. E., McHugh, M. D., & Kutney-Lee, A. (2023). Electronic health record
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usability and post-surgical outcomes among older adults with dementia. The American
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Journal of Geriatric Psychiatry. https://doi.org/10.1016/j

.jagp.2023.02.004
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Innab, A. M. (2022). Nurses’ perceptions of fall risk factors and fall prevention strategies
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in acute care settings in Saudi Arabia. Nursing Open, 9(2).

https://doi.org/10.1002/nop2.1182
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Liu, Q., Yu, Y., Wu, X., Sun, Y., Lyu, Y., Cao, K., Wang, Y., & Geng, L. (2023). Demand
for community medical-nursing combined services among the empty-nest elderly in
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China: A qualitative study. Health & Social Care in the Community, 2023, e2173057.
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https://doi.org/10.1155/2023/2173057

Strachna, O., Asan, O., & Stetson, P. D. (2022). Managing critical patient-reported
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outcome measures in oncology settings: System development and retrospective study.

JMIR Medical Informatics, 10(11), e38483. https://doi.org/10.2196/38483
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Vareta, D. A., Ventura, F., Família, C., & Oliveira, C. (2022). Person-centered practice in
hospitalized older adults with chronic illness: Clinical study protocol. International
Journal of Environmental Research and Public Health, 19(17), 11145.
https://doi.org/10.3390/ijerph191711145

Wolff, J. C., Maron, M., Chou, T., Hood, E., Sodano, S., Cheek, S., Thompson, E.,
Donise, K., Katz, E., & Mannix, M. (2023). Experiences of child and adolescent
psychiatric patients boarding in the emergency department from staff perspectives:
Patient journey mapping. Administration and Policy in Mental Health and Mental Health
Services Research, 50, 417–426. https://doi.org/10.1007/s10488-022-01249-4

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