Collaboration For Improving Outcomes Discharge Plan Descript ✓ Solved
Collaboration For Improving Outcomes Discharge Plandescription The
The collaboration for improving outcomes – discharge plan description: The baccalaureate graduate nurse will conduct a health history to identify current and future health problems.
Course Competencies include developing a holistic case management plan that incorporates insurance, healthcare finance, and community resources. The nurse will coordinate patient care across the lifespan using interdisciplinary models of care and case management.
QSEN competencies involve patient-centered care, teamwork and collaboration, and evidence-based practice. The assessment covers general information, current medications, activities of daily living, support systems, medical follow-up, and financial summaries.
The diagnosis/plan includes establishing priorities, nursing diagnoses, client outcomes/goals. Education needs involve identifying needs, methods, and evaluation. The financial worksheet encompasses future medical care, medications, supplies, testing, treatments, equipment, transportation, home modifications, potential complications, and financial summaries.
Reflection and conclusion require interpreting the plan of care and providing a comprehensive summary. Proper APA formatting, grammar, spelling, and punctuation are essential, with up to three errors acceptable. A minimum of two references must be provided.
Sample Paper For Above instruction
Introduction
The discharge planning process is a critical component of holistic patient care, aimed at ensuring seamless transition from hospital to home or another care setting. A comprehensive discharge plan involves identifying the patient's ongoing needs, coordinating care, and involving interdisciplinary teams to optimize outcomes. This paper illustrates a detailed discharge plan for a hypothetical patient, integrating assessments, diagnoses, education strategies, and financial considerations, aligned with nursing competencies and evidence-based practices.
Assessment
The patient, a 65-year-old male with a history of hypertension and type 2 diabetes, was admitted for congestive heart failure (CHF). The health history revealed medication adherence issues, limited social support, and difficulty managing daily activities due to fatigue. Past medical history included coronary artery disease, previous myocardial infarction, and knee replacement surgery. The physical assessment documented edema, elevated blood pressure, and decreased activity tolerance.
Current medications included lisinopril, metformin, and furosemide. Activities of daily living assessment indicated dependence in shopping, housework, and medication management. Support systems comprised a daughter living nearby and a visiting home health nurse. The patient expressed concern about medication costs and transportation for follow-up visits.
Diagnosis and Priority Setting
- Priority 1: Prevent readmission due to CHF exacerbation.
- Priority 2: Improve medication adherence.
- Priority 3: Enhance support system involvement.
Nursing Diagnoses
- Decreased cardiac output related to fluid overload as evidenced by edema and dyspnea.
- Nonadherence to medication regimen related to cost and understanding as evidenced by missed doses.
- Impaired social support system related to limited family involvement.
Client Outcomes/Goals
- Patient will demonstrate understanding of CHF management within one week of discharge.
- Patient will adhere to prescribed medication regimen with zero missed doses over the next month.
- Patient will identify at least two community resources to support ongoing care within two weeks.
Education Needs and Strategies
| Need | Method | Evaluation of Learning |
|---|---|---|
| Understanding of CHF symptoms and management | Demonstration, discussion, printed materials | Return demonstration of symptom monitoring and medication administration |
| Medication adherence importance | Teach-back method, written instructions | Patient correctly describes medication schedule and purpose |
| Utilizing community resources | Referral to social services and community programs | Patient identifies resources and commits to utilization |
Financial Planning
The financial worksheet includes assessing costs related to future medical care, medication expenses, supplies, and transportation. Routine visits are scheduled quarterly to monitor CHF status, with an estimated annual cost based on provider fees and medication expenses. Adequate insurance coverage and assistance programs are explored to mitigate financial burden.
Interventions and Care Coordination
Care interventions involve medication teaching, symptom monitoring, and arranging for home health services. Equipment such as blood pressure monitors and mobility aids are procured through rental programs. Transportation services are scheduled to ensure attendance at follow-up appointments. Home modifications include raised seating and ramps if necessary to facilitate mobility and safety.
Reflection and Conclusion
The discharge plan demonstrates a comprehensive, interdisciplinary approach to patient care, emphasizing education, social support, financial management, and follow-up strategies. This approach promotes patient safety, self-management, and reduces the risk of readmission. The plan also highlights the importance of collaboration among healthcare providers, family, and community resources in achieving optimal health outcomes.
References
- Clark, M. M., & Brien, S. (2019). Effective Discharge Planning: Approaches and Strategies. Journal of Nursing Management, 27(5), 982–989.
- Johnson, P., & Smith, L. (2020). Community Resources and Chronic Disease Management. American Journal of Public Health, 110(4), 453–459.
- Kelly, M., et al. (2021). Patient Education and Engagement in Heart Failure Care. Nursing Clinics of North America, 56(2), 193–206.
- Lee, H., & Kim, E. (2018). Financial Considerations in Discharge Planning. Healthcare Financial Management, 72(3), 78–85.
- Miller, A., & Davis, R. (2022). Interdisciplinary Models for Discharge Planning. Journal of Interprofessional Care, 36(1), 23–30.
- National Heart, Lung, and Blood Institute. (2021). Heart Failure: Management and Treatment. NIH Publication.
- Rosenberg, S., & O’Neill, J. (2020). Strategies for Promoting Medication Adherence. Patient Education and Counseling, 103(6), 1382–1388.
- Smith, J., & Patel, N. (2019). Discharge Planning: Evidence-Based Best Practices. Journal of Hospital Medicine, 14(2), 87–94.
- Williams, R., & Thomas, K. (2021). The Role of Social Support in Chronic Disease Outcomes. Social Science & Medicine, 267, 113345.
- World Health Organization. (2020). Disability and Rehabilitation. WHO Press.