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NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment

Student Name

Capella University

NURS-FPX 6610 Introduction to Care Coordination

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Comprehensive Needs Assessment

Conducting a comprehensive needs assessment is imperative for healthcare professionals to utilize diverse resources that enhance patient care. This assessment is crafted to identify gaps in patient care and address them through effective care coordination. It also facilitates the recognition of patients’ needs and the development of strategies to assess and meet those needs. The importance of care coordination in patient care is emphasized, and various strategies to enhance patient care are explored. The assessment also delves into interdisciplinary team collaboration in the context of care coordination.

Current Gaps in Patient Care

A case study involving a 79-year-old diabetic patient, Mr. Decker, illustrates existing gaps in patient care. Factors such as Mr. Decker’s low-income status, insufficient communication about post-discharge care, and lack of post-discharge evaluation contribute to gaps in his care. Utilizing the Patient-Centered Assessment Method, the assessment tool emphasizes an effort-based approach to address not only Mr. Decker’s physiological needs but also his social, religious, and psychological requirements (Perazzo et al., 2020).

Informational Needs for Optimal Patient Care

To assess the current level of care, essential patient information includes medical records (e.g., age, weight, allergies), emotional behavior, desires, medical schedule, and religious beliefs. Gathering additional necessary data involves conducting preliminary discussions and interviewing Mr. Decker’s family members, considering factors such as his interests, diet, and social connections. Electronic health records, patient registration documents, and routine follow-up procedures are also employed, ensuring adherence to HIPAA compliance (Shah & Khan, 2020).

Societal, Economic, and Interdisciplinary Factors Impacting Patient Care

Factors such as financial crisis, aging, and insufficient social support significantly impact patient care. Aging, in particular, poses additional risks for complications in chronic patients like Mr. Decker. Economic determinants, such as Mr. Decker’s low income, affect his access to recommended therapies. Limited social support from family members further complicates post-discharge procedures, potentially leading to serious complications (Ko et al., 2019; Palileo-Villanueva et al., 2022).

Professional Standards and Care Coordination Outcomes

Organizations like the National Quality Forum and the Agency for Healthcare Research and Quality play crucial roles in establishing standards for safety, care coordination outcomes, and evaluation benchmarks. Models such as the Care Coordination and Transition Management Logic Model and evidence-based practices contribute to effective care coordination, focusing on patient-centered care and multidisciplinary collaboration (Hofmann & Erben, 2020; Artiga et al., 2020).

Evidence-Based Practices for Patient Care Coordination

Evidence-based strategies like GENESIS, routine evaluation of older patients, and the sepsis six bundles are recommended for managing elderly patients with infection. These practices aim to identify and address infection outbreaks, monitor essential signs, and provide timely interventions to reduce mortality rates associated with sepsis (Kregel et al., 2022; LeRoith et al., 2019; Bleakley & Cole, 2020).

Benefits of a Multidisciplinary Approach to Patient Care

A multidisciplinary approach in healthcare enhances patient care by considering various aspects of a patient’s health simultaneously. This approach minimizes errors, particularly those related to socioeconomics and age-related variables. Mr. Decker’s care gaps, influenced by social, economic, and interprofessional factors, could have been mitigated through a multidisciplinary team. Research suggests that a multidisciplinary approach can reduce readmissions and provide more thorough care to patients (Ni et al., 2019).


In conclusion, care coordination is integral for improving overall patient care quality. Identifying and addressing gaps in patient care, particularly those influenced by socioeconomic, age-related, and interdisciplinary factors, requires a comprehensive needs assessment. This assessment, coupled with evidence-based practices and adherence to professional standards, contributes to enhanced patient care. The incorporation of a multidisciplinary approach further strengthens patient care outcomes.


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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

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NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment

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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

Villanueva, L. M.P., Palafox, B., Amit, A. M. L., Pepito, V. C. F., Ab-Majid, F., Ariffin, F., Balabanova, D., Isa, M.-R., Mat-Nasir, N., My, M., Renedo, A., Seguin, M. L., Yusoff, K., Dans, A. L., & Mckee, M. (2022). Prevalence, determinants and outcomes of traditional, complementary and alternative medicine use for hypertension among low-income households in Malaysia and the Philippines. BMC Complementary Medicine and Therapies, 22(1). https://doi.org/10.1186/s12906-022-03730-x

NURS FPX 6610 Assessment 1 Comprehensive Needs Assessment

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