NURS FPX 6614 Assessment 2 Enhancing Performance as Collaborators in Care

Student Name

Capella University

NURS-FPX 6614 Structure and Process in Care Coordination

Prof. Name:

Date

Enhancing Performance as Collaborators in Care Presentation

Hello everyone, welcome to my presentation. I am —–, and today, I will highlight the critical significance of interprofessional collaboration for delivering high-quality care treatments that aim to provide coordinated care and enhance patient safety. The gap in practice identified was the need for more use of Electronic Health Records (EHR) to facilitate care coordination for treating adults with chronic health conditions. Let’s discuss the agenda for how the interdisciplinary team can play an impactful role in this scenario.

Agenda

I will discuss the following content in my presentation:

Steps to improve interprofessional collaboration
Services and resources to educate chronic disease patients among adults
Outcomes of new process
Evaluation of outcomes
Ethical considerations

Steps to Improve Interprofessional Collaboration in an Evidence-Based Practice for Adults with Chronic Conditions

The adults with chronic conditions are in dire need of long-term care with a consistent effort of interdisciplinary team members. By improving interprofessional collaboration in Evidence-Based Practice (EBP) for elderly patients with chronic health conditions, healthcare professionals can provide the right care treatments with improved quality of care and patient safety (Pascucci et al., 2020). The following steps entail the necessary information that can potentially enhance multidisciplinary team collaboration in EBP for the targeted population of chronic diseases:

Healthcare leaders must clearly outline the roles and responsibilities of each healthcare professional involved in caring for elderly people suffering from chronic health conditions (Weiner et al., 2020).
Once the role clarity is performed, leaders must develop effective and clear communication strategies to facilitate information sharing among team members. Using technology such as EHR or patient portals can exchange information regarding patient health among healthcare professionals from multiple disciplines. This will help improve communication and collaboration in the decision-making process for elderly people with chronic diseases (Pascucci et al., 2020).
It is crucial to offer ongoing education and training programs to enhance the knowledge and skills of healthcare professionals in different fields. By building awareness of each discipline’s contributions in delivering EBP for chronic disease treatment, interprofessional collaboration will be efficient, and treatment can be effectively delivered, attaining the desired goals of patient safety and quality of care (Pascucci et al., 2020).
Encouraging a supportive environment is necessary for an enhanced contribution towards the interprofessional care coordination process. This can be possible by building trust among team members when their efforts are recognized in chronic care management among adults (Pascucci et al., 2020).

Strategic Planning

To achieve interprofessional collaboration for chronic care management among elderly people, planning strategically to lead to desirable outcomes is crucial. First, the healthcare leading team must identify the current state of interprofessional collaboration within a healthcare setting and the needs to address in delivering coordinated care to chronic disease patients. Additionally, SMART goal setting establishes specific, measurable, achievable, relevant, and time-bound goals for improving collaboration in the care coordination process of chronic care for the elderly (Boeykens et al., 2022).

Resources will be allocated adequately for training team members, integrating technology, and implementing the plan in the pilot phase, then expanding it throughout the unit with chronic disease patients. Lastly, the planned steps will be implemented following the consideration of EBP for chronic care management of elderly people. The quality control department will conduct quality assurance of the implemented plan by analyzing pre- and post-implementation dashboard metrics such as hospital readmission rates, patient satisfaction scores, and healthcare cost analysis (Pascucci et al., 2020).

NURS FPX 6614 Assessment 2 Enhancing Performance as Collaborators in Care

The underlying assumptions on which this analysis is based include that integrating interprofessional collaboration can lead to delivering coordinated care, which is an evidence-based practice in managing chronic health conditions such as diabetes, hypertension, etc. Moreover, technology can enhance communication and collaboration, which is crucial for the interprofessional care approach in chronic disease management (Davidson et al., 2022). Following are some insightful suggestions that must be considered to improve the outcomes of an interprofessional team approach in the care of chronic disease patients among older people:

Introduce incentives that recognize and reward collaborative efforts, such as acknowledging interprofessional achievements, providing professional development opportunities tied to successful collaboration, or bonuses in salary (Aggarwal et al., 2023).
Recognize and celebrate the diversity of perspectives within multidisciplinary team members. Ensure all team members feel included and valued, as diverse teams often bring innovative solutions to complex chronic health conditions (Aggarwal et al., 2023).
Empower patients with knowledge about their conditions and the significance of collaborative care. This will improve patient collaboration with interprofessional teams and result in greater chances of adherence to treatment plans (Davidson et al., 2022).

Educational Services and Resources for Adults with Chronic Diseases

Several educational services and resources can be used to educate adults with chronic diseases. The educational services include crafting individual educational plans for chronic disease patients and telehealth-based educational consultations. The resources that educate chronic disease patients include digital health platforms and printed educational brochures and pamphlets. These resources will help them manage their chronic diseases efficiently and promote self-management. Moreover, they will enable them to collaborate with healthcare professionals effectively as their knowledge of improving their health conditions is enhanced. The selected services and resources for this targeted audience include developing individualized health educational plans tailored to each patient’s chronic disease, health status, learning ability, and preferences (Huang et al., 2020).

For this purpose, certified health educators will conduct one-on-one sessions with patients to deliver educational services that meet their unique health needs and literacy levels. Printed educational materials such as pamphlets, brochures, and booklets can offer digestible information about managing chronic diseases, medication adherence, and support service tools (Tzenios, 2023). Other educational resources will be digital platforms such as mobile apps or websites to deliver interactive and engaging educational content on chronic conditions. This can include video tutorials, virtual support groups, and interactive educational games and quizzes. For this purpose, the healthcare IT team can build software and apps for chronic disease patients among adults (Agarwal et al., 2021).

Summary of Interprofessional Collaboration Plan

The following collaboration plan includes the summary of interprofessional collaboration and coordination to facilitate the effective management of chronic conditions among adults. Regular interprofessional team meetings will strengthen interprofessional collaboration and partnership to facilitate collaborative information sharing, discussing patient scenarios with complex health needs, and joint decision-making (Davidson et al., 2022). Additionally, team-based care plans with comprehensive outlines of the roles of each member will be developed. This will help improve collaborative care plans and optimize healthcare delivery (Sibbald et al., 2020).

Furthermore, cross-training interprofessional team members will help team members learn about each other’s roles and responsibilities. Consequently, mutual understanding and communication will be enhanced. Lastly, the technology tool of EHR will be used throughout the care treatments of chronic disease patients to facilitate remote communication and collaboration without physical meetings (Awad et al., 2021).

The team members will first develop a comprehensive interprofessional team according to the patients suffering from chronic disorders. They will further assess adults’ medical histories and lifestyles with chronic diseases. This will be done by scrutinizing their past medical records and brief discussions about their lifestyle (Davidson et al., 2022). This will be followed by making interprofessional and coordinated care plans for targeted patients by communicating clearly and openly in team meetings. Lastly, the shared decision will be implemented, and chronic disease monitoring will be continued during follow-up care. This will pave further ways to integrate improvement in the treatment plan and empower the patient to sustain their health condition through lifestyle modification and adherence to the treatment plan (Pascucci et al., 2020).

Outcomes of the New Process

As a result of improved interdisciplinary collaboration, the substantial outcomes related to chronic health conditions among adults will be as follows:

Enhanced patient satisfaction: When interprofessional team members collaboratively deliver care treatments to chronic disease patients and tailor the treatment plans to their health needs and preferences, patient satisfaction is enhanced due to better communication, coordinated care, and adherence to treatment plans (Pascucci et al., 2020).
Reduction in hospital readmission rates: Integrating interdisciplinary team collaboration in delivering coordinated care results in better-managed chronic diseases and fewer hospital emergency visits and readmission rates. Moreover, the collaborative care approach for adults with chronic diseases prevents errors in the transition process, as one study showed a decline in hospital readmissions by 60% in 90 days of follow-up (Nall et al., 2020). It promotes effective discharge where the patient is adequately educated on managing their health condition.
Improved health outcomes and quality of life: Patient-reported outcomes and feedback after coordinated care delivery can depict improved health outcomes and quality of life. The timely detection and interventions by interprofessional team care approach lead to adherence to evidence-based practices and personalized care plans, leading to better health outcomes and improved quality of life (Davidson et al., 2022).

Evaluation of Outcomes

The evaluative measures that hospital administrations can utilize to estimate the success of outcomes include conducting regular audits and reviews of care coordination processes to identify deviations from established protocols (Rawlinson et al., 2021). Additionally, qualitative feedback from patients and interprofessional team members can help analyze the outcome measures through interviews and discussions. Lastly, dashboard metrics such as hospital readmission rates, healthcare costs, and patient satisfaction rates can be assessed and compared to established benchmarks to ensure the success of the interprofessional care approach toward chronic care management among elderly people (Morgan et al., 2020).

Considering the evidence-based outcomes by integrating an interprofessional care approach for effectively managing chronic diseases among adults, it is essential to implement this approach and strive to deliver high-quality care treatments to these patients. This will result in higher patient safety rates and reduced mortality rates, which usually escalate when chronic conditions are not well-managed. A healthier community can ultimately be sustained, and healthcare costs can be reduced when proactive interdisciplinary care is delivered (Pascucci et al., 2020). While the positive impact of team-based chronic care prevails, it is imperative to acknowledge the potential underlying assumptions and uncertainties, such as variations in healthcare organizations and the need for ongoing adaptation to achieve sustained improvement.

There may be many barriers to achieving these goals through a multidisciplinary team approach, such as communication barriers, technological barriers, and obstacles related to varied perspectives among diverse healthcare professionals (Rawlinson et al., 2021). These assumptions and uncertainties must be adequately addressed to foster an interprofessional team care approach for chronic disease patients in healthcare settings.

Ethical Considerations

Coming to the last section of our presentation, I highlight some ethical considerations that advocate for the pressing need for change within chronic care management for adults. The ethical principles underlying care coordination for adults suffering from chronic diseases emphasize respecting patients’ autonomy and promoting beneficence. Improved interprofessional collaboration focuses on personalized and patient-centered care plans, respecting the autonomy of each patient with a chronic ailment by involving them in decision-making processes (Lindblad, 2021). Additionally, this collaborative care approach aims to enhance the well-being of elderly patients, fulfilling the ethical principle of beneficence. Furthermore, the ethical responsibility to provide education aligns with the need to empower patients with knowledge about their chronic condition and the importance of collaborative care (Lindblad, 2021).

This calls for supporting the change, including patient education and informed decision-making to ensure patients understand the implications of their health choices. Lastly, the standard of collaboration in healthcare practice is also an ethical imperative in care coordination, which promotes teamwork and shared decision-making to benefit patient health outcomes (McAuliffe, 2021). This supports the change that centers on enhancing interprofessional collaboration by acknowledging the ethical duty to work collaboratively with diverse healthcare professionals to optimize healthcare. Through collaborative care plans, the change supports the ethical principle of patient-centered teamwork, where each member contributes to the overall well-being of patients suffering from chronic disease. These ethical considerations align with the proposed change and ensure a morally sound, patient-centered approach to healthcare delivery for adults with chronic diseases (McAuliffe, 2021).

Conclusion

To conclude, interprofessional collaboration is imperative for effectively managing chronic disease among adults. This requires the implementation of strategic steps and planning where team members coordinate cohesively to tailor treatment plans to specific diseases and health needs of patients. Moreover, educational content in services and resources can benefit patients with chronic health conditions to promote collaboration and self-management. The plan’s outcomes include enhanced patient safety, better health outcomes, and quality of life. The ethical considerations also support implementing the proposed change to manage chronic conditions among adults.

References

Agarwal, P., Gordon, D., Griffith, J., Kithulegoda, N., Witteman, H. O., Sacha Bhatia, R., Kushniruk, A. W., Borycki, E. M., Lamothe, L., Springall, E., & Shaw, J. (2021). Assessing the quality of mobile applications in chronic disease management: A scoping review. Npj Digital Medicine, 4(1). https://doi.org/10.1038/s41746-021-00410-x

Aggarwal, M., Hutchison, B., Kokorelias, K. M., Mehta, K., Greenberg, L., Moran, K., Barber, D., & Samson, K. (2023). Impact of remuneration, extrinsic and intrinsic incentives on interprofessional primary care teams: Protocol for a rapid scoping review. BMJ Open, 13(6), e072076. https://doi.org/10.1136/bmjopen-2023-072076

Awad, A., Trenfield, S. J., Pollard, T. D., Ong, J. J., Elbadawi, M., McCoubrey, L. E., Goyanes, A., Gaisford, S., & Basit, A. W. (2021). Connected healthcare: Improving patient care using digital health technologies. Advanced Drug Delivery Reviews, 178(1), 113958.

Boeykens, D., Boeckxstaens, P., De Sutter, A., Lahousse, L., Pype, P., De Vriendt, P., & Van de Velde, D. (2022). Goal-oriented care for patients with chronic conditions or multimorbidity in primary care: A scoping review and concept analysis. PLOS ONE, 17(2), e0262843. https://doi.org/10.1371/journal.pone.0262843

Davidson, A. R., Kelly, J., Ball, L., Morgan, M., & Reidlinger, D. P. (2022). What do patients experience? Interprofessional collaborative practice for chronic conditions in primary care: An integrative review. BMC Primary Care, 23(1). https://doi.org/10.1186/s12875-021-01595-6

NURS FPX 6614 Assessment 2 Enhancing Performance as Collaborators in Care

Huang, L., Guo, H., Xiu, L., & Wang, H. (2020). Efficacy of individualized education in patients with type 2 diabetes mellitus. Medicine, 99(50), e23625. https://doi.org/10.1097/md.0000000000023625

Lindblad, T. L. (2021). Ethical considerations in clinical supervision: Components of effective clinical supervision across an interprofessional team. Behavior Analysis in Practice, 14(2). https://doi.org/10.1007/s40617-020-00514-y

McAuliffe, D. (2021). Interprofessional ethics. In Google Books. Cambridge University Press. https://books.google.com/books?hl=en&lr=&id=HGlHEAAAQBAJ&oi=fnd&pg=PR11&dq=ethical+considerations+in+interprofessional+care&ots=Rwu0RSCLjm&sig=ZwVWrYIjId3u0R1pttbfsssibf4

Morgan, K. H., Barroso, C. S., Bateman, S., Dixson, M., & Brown, K. C. (2020). Patients’ experiences of interprofessional collaborative practice in primary care: A scoping review of the literature. Journal of Patient Experience, 7(6), 1466–1475. https://doi.org/10.1177/2374373520925725

Nall, R. W., Herndon, B. B., Mramba, L. K., Vogel-Anderson, K., & Hagen, M. G. (2020). An interprofessional primary care-based transition of care clinic to reduce hospital readmission. The American Journal of Medicine, 133(6), e260–e268. https://doi.org/10.1016/j.amjmed.2019.10.040

Pascucci, D., Sassano, M., Nurchis, M. C., Cicconi, M., Acampora, A., Park, D., Morano, C., & Damiani, G. (2020). Impact of interprofessional collaboration on chronic disease management: Findings from a systematic review of clinical trial and meta-analysis. Health Policy, 125(2). https://doi.org/10.1016/j.healthpol.2020.12.006

Rawlinson, C., Carron, T., Cohidon, C., Arditi, C., Hong, Q. N., Pluye, P., Peytremann-Bridevaux, I., & Gilles, I. (2021). An overview of reviews on interprofessional collaboration in primary care: Barriers and facilitators. International Journal of Integrated Care, 21(2), 32. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8231480/

Sibbald, S. L., Ziegler, B. R., Maskell, R., & Schouten, K. (2020). Implementation of interprofessional team-based care: A cross-case analysis. Journal of Interprofessional Care, 1–8. https://doi.org/10.1080/13561820.2020.1803228