Patient Care Discharge Planning Case Study – NURS_FPX6612_Assessment 3

Most hospitals are currently faced with the immense financial pressure to release patients sooner while guaranteeing high-quality care and patient safety in our current value-based environment. Care discharge planning aims to guarantee quality care between the hospital and the respective community. Care coordination will ensure that the patient gets safe, personalized, and high-quality care (Sailsman et al., 2018). In addition, the purpose of the discharge design is to reduce unplanned hospital admissions and scale back the duration of stay in the hospital. The care coordination will incorporate the effective integration of personnel and services from different care disciplines and settings. Nowadays, care coordination mostly concentrates on managing client problem lists, confirming medications, scheduling and coordinating appointments, changing patients between care levels, tracking care gaps, and offering required social and psychological support. Coordinated care can be achieved in two ways; the first is through precise care coordination activities, and the second is through broad approaches. There are five major care coordination modules: health home, vision/supportive environment/leadership, systematic measurement and feedback, proactive care plan and follow-up, communication, and health information technology systems (HIT). Health information technology systems (HIT) will help share and transfer information since immediate accessibility to the information will guarantee the delivery of quality health care (Chan et al., 2018).

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Health information technology systems (HIT)

The health information technology systems were created and designed to help in the clinical setting by improving documentation in the discharge area. The discharge summaries often lack significant information, such as pending tests at discharge, and are not accessible to the clinicians/doctors who need them for discharge purposes. The specialist, primary care doctor, and health agency could also not get the missing important information in the summaries. Healthcare facilities with highly innovative HIT have encountered fewer complications, lesser healthcare costs, and lower mortality than hospitals with less advanced health electronic systems. HIT can make healthcare facilities more uniform and eventually lead to standardized care. One of the major components of health information technology systems (HIT) is to lower the cost of healthcare (Sailsman et al., 2018). The embracing of HIT has significantly increased as integrated healthcare models have grown. These models consist of Patient-Centered Medical Homes, Affordable care organizations, and health homes (Sailsman et al., 2018). Care coordination in patient-centered care has been made more impactful through various aspects such as group care, care transitions, individual health records, telehealth, and support of clinical decisions (Sailsman et al., 2018). Health information technology can offer several elements at discharge for families, patients, providers, and post-discharge establishments.

1. Patient-centered care plans: The data available and clinical assessments can enable the creation of a post-discharge care plan through the collaboration of the patient and the health provider. The patient’s needs, resources, and preferences will be reflected in the care plan since it will be specific to the patient. The patient is most likely to stick to the care plan since the hospital will offer continuous support, which is likely to deliver an optimal outcome. Patient-centered care seeks to address the population’s health issues by offering better care and improved patient experience at a lower cost; it also fosters risk reduction approaches, supports clinical choices, and access to quality care. Patient-centered care aims to develop a successful transition that can only be realized through care coordination. It also seeks to lower hospital readmission, which can only be met through quality care and enhanced safety. It will also address the complicated needs of the patient, precautionary care management, and chronic management. This will ensure that Maria is successful after discharge.
2. Health education: Low health literacy has contributed to the struggles most patients face when it comes to following the discharge instructions by patients or the patients adhering to medications as they have been prescribed. Health information technology systems can provide systematic continuous education on new chronic conditions, new diagnoses, and new medication. The nurse or healthcare provider will print and review the pre-populated education with the preferred medication or diagnosis at discharge. The main purpose of the education is to make it patient-centered; hence it will be specific to Maria’s needs as well as in the Spanish language.
3. Telemedicine: Furthermore, the purpose of telehealth is to offer health assessment, consultations, interventions, education, diagnoses, and information over a distance. Most acute care hospitals have incorporated telehealth in patient care management. The in-person visit will decline due to improvement in certain chronic disease outcomes, increasing patient compliance, and engagement. The current data on telehealth proposes that the effect of cost and patient outcomes are moderate to large. Telehealth is used to help with procedures to be done outside the town. In addition, studies have shown that populations such as children and teenagers feel more at ease when taking part in virtual therapy sessions in their homes than in hospitals or provider institutions (Gibson et al., 2020). Telehealth has shown great potential in developing virtual health homes with incorporated group-based approaches to care, in which human services, healthcare services, nutrition, and mental health services are integrated (Arendset et al., 2021). For instance, in Maria’s scenario, her family can communicate 24 hours a day with the nurse after discharge. Maria’s family can ask questions or voice their concerns during post-care. Telehealth will still ensure the patient remains at the center of care at home and not necessarily in the hospital.
4. Availability of hospital data to patient: The available technology will enable Maria to log into the hospital healthcare system to review her forthcoming appointment and ensure compliance after discharge. Maria will be able to share her hospital data with post-acute care providers by refreshing her memory of her lengthy hospitalization. In the instance that the healthcare provider cannot share clinical information easily, Maria’s ability to refresh herself will be helpful due to the available technology. It will be crucial that there is reconciliation medication designed after post-discharge to avoid severe drug interactions.

Data reporting

Care coordination assesses the usage of data from health information technology systems or other electronic health records, which can be of great importance to the patient and health care systems since it will highlight what is working in the health care system as well as what needs to be improved (Knight et al.,2020). Many challenges are faced during patient discharge, and this makes this process to become complicated. Care coordination centered on the patient can be for a multi-level or individual patient population health approach. Within the United States, more than thirty-five million discharges happen yearly. Nearly 15 to 20 billion dollars is spent on unplanned readmissions yearly. The financial well-being and quality of patient care can be improved by averting avoidable readmissions (Pugh et al., 2022). Access to data is crucial for achieving program goals, and meaningful and relevant measures should be reflected in the data accessed. What cannot be measured cannot be managed since that’s an impossible expectation.

The available health information technology systems (HIT) can show compliance post-discharge by recording the information from follow-up visits and preventable care. The healthcare provider can eliminate gaps in specific patient care and avoid duplicative services in the present time through alerts and reminders generated by the latest HIT systems. This allows doctors to consistently offer quality care to their patients since the care is supported by evidence. Based on the cost of health and the potential severity of the condition, most healthcare establishments incorporate data analytics to enlighten their care coordination plan in identifying and grouping patients. Furthermore, the cultural, behavioral, socioeconomic, environmental factors, and lifestyle commonly disclosed by care providers are significant in enhancing patient outcomes, prioritizing, and handling patient care. Plenty of data sets are created when patient outcomes are regularly measured, and this data will enhance patients’ results in a particular way. The data obtained from beside monitors, ventilators, infusion pumps, and peacemakers are significantly used in patient care. The data can be shared from the devices and loaded into electronic medical records. Healthcare professionals are able to view the information without a visit. The HIT has to be able to transform how we think about care coordination since it has to enable health providers to collect data from patients without a physical visit, and this is due to the ability of HIT to collect information. A major role has been played by health informatics in achieving this process. Healthcare professionals can enhance patients’ outcomes by accurately collecting, leveraging on the data, and analyzing the data to identify at-risk patients, enhance the process, and improve efficiency and analysis in pursuit of better patient care (Pugh et al., 2022). Ultimately, information reporting and collection are beneficial to the patients in ways such as improved management and access to health information, shortened turnaround treatment time, improved usage of best practices that are evidenced-based, advanced medical treatment, higher cost savings, greater responsibility for personal care, reminders and alerts in the forthcoming appointments, increased satisfaction, and decrease in the number of unnecessary procedures.

Data influencing outcomes positively.

Patients are bound to receive better treatment when physicians have complete access to accurate and reliable data (Qiu et al., 2019). The current and latest HIT will assist in offering international standards in applications that incorporate social, behavioral, economic, health, and environmental information to communicate, elucidate and act brilliantly upon complicated information systems to strengthen carefulness in medicine and an educative health system. The patient information that has been incorporated into the electronic health records consists of; medications, allergies, vital signs, immunization dates, patient demographics, lab tests, billing data, radiology images, progressive notes, administrative data, and lab tests. Electronic health records’ benefits include the following:

• Enhanced patient care.
• An upsurge in patient participation.
• Enhanced care coordination.
• Improved patient outcomes and diagnostics.
• Cost saving.
• Effective practice.

The capability to diagnose diseases, reduce medical errors, and improve patient outcomes will be achieved through Electronic health records (EHR_s) (Qiu et al., 2019). Electronic health records allow the transfer of information between healthcare professionals and other organizations, such as medical imaging centers, laboratories, specialists, emergency facilities, pharmacies, workplace clinics, and schools. The electronic health records will provide detailed information concerning the patient. A recent survey carried out nationally of physicians who are willing to use EHR_s proposes.

• 94% of the healthcare providers stated that Electronic health records ensure records are accessible daily at the point of care.
• 88% stated that their Electronic health records generate clinical advancement for the practice
• 75% of the healthcare professionals stated that their Electronic health records enable them to offer better patient care

The data collected and recorded in Electronic health records by the immediate care physician will inform other healthcare professionals in various departments of the healthcare system concerning a patient’s severe allergies or allergic reactions, and those providers will modify care appropriately (Clarke & Ghersi, 2022). However, the patient may be unable to talk or out of consciousness. New technologies play a crucial role in care management programs. The current patient care highly depends on several medical devices to observe the patient’s vital signs, sustain patients on life support, and infuse the medication. The data obtained from medical devices such as infusion pumps, monitors, ventilators, and transferrable monitors are linked with the Electronic health records via a custom interface program. Besides the patient data being important for Electronic health records, it is also significant for supporting clinical choices, which are used to avert harm and enhance patient outcomes (Clarke & Ghersi, 2022). The usage of EMR technology with HIT has been able to reduce medical errors by encouraging and reminding patients of their forthcoming appointment; patients have shown satisfaction with the care offered by their providers, and the prescription incorporated has resulted in fewer medical errors (Qiu et al., 2019). Numerous studies have supported using the electronic database, and Electronic health records have been identified as one of the principal elements in improving healthcare systems. They assist in reducing medical errors and maintaining care continuously when patients are changing or moving from one hospital to the other (Clarke & Ghersi, 2022). The complete healthcare community is affected by Electronic health records, comprising pharmacies, hospitals, public health organizations, researchers, healthcare providers, and clients; computerize and simplify the physicians’ workflow; enable management of costs, and foster the various facets of the healthcare industry.

Conclusion

Some challenging and complicated moments in the healthcare system are during patient movement from one hospital to another or during discharge planning. The clients and healthcare professionals have benefited largely from the numerous benefits of health information technology. The innovation and development of the latest practice models offer effective healthcare at a lesser cost while at the same time enhancing patient safety and joint processes within the healthcare system. Patient quality care, safety, and care efficiency have been improved through the solutions provided by HIT. Appropriate discharge designing aims to facilitate workflow and aims to streamline the workflow. Care coordination enhances outcomes for both the population and individual while simultaneously improving the satisfaction of the inter-professional care group’s clinical members and care providers as they offer cost-effective, compassionate, and safe care. Care coordination seeks to support clinical decisions to better the client’s experience. Most hospital readmission can be reduced through effective communication between the coordination of the various healthcare system departments.

Reference

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Chan, H. Y. L., Ng, J. S. C., Chan, K. S., Ko, P. S., Leung, D. Y. P., Chan, C. W. H., … & Lee, D. T. F. (2018). Effects of a nurse-led post-discharge advance care planning programme for community-dwelling patients nearing the end of life and their family members: a randomised controlled trial. International journal of nursing studies, 87, 26-33.

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Pugh, J. D., McCoy, K., Williams, A. M., Pienaar, C. A., Bentley, B., & Monterosso, L. (2022). Neurological patient and informal caregiver quality of life, and caregiver burden: A cross-sectional study of post-discharge community neurological nursing recipients. Contemporary nurse, (just-accepted), 1-27.

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