MSN FPX 6610 Comprehensive Needs Assessment

Sample Answer

Current Gaps in a Patient’s Care

While the Affordable Care Act has been efficacious in expanding insurance coverage for most Americans, its impact on diabetes care is hardly known. Thus, it is difficult to assess the effect of this legislation on diabetes outcomes. Of course, the fact that ACA has enabled early diagnoses of diabetes for most people is a positive impact. Similarly, earlier treatment of diabetes reduces mortality rates in the United States. However, this law has not helped many Americans in managing conditions associated with diabetes.

For instance, in the case of Mr. Decker, he did not have his toe infection treated as early as required, which made the wound worse and would have required an amputation. Also, he did not have much family support, and his wife reports that he often forgets to take his medication. His daughter is outside the country and is unavailable to provide additional support and his nephew faces problems while trying to help.

The policy requiring elderly patients to receive diabetes care under Medicare faces constant challenges associated with funding. It also limits itself to the amount allocated to patients. In the case of Mr. Decker, Medicare wanted him to get out of the hospital after receiving primary care, but there are fears that he will not receive the care he needs at home. His continued hospitalization may not help because of the increasing cost of care. The family has to pay out of their pocket to access care outside the home.

The current policy relating to Mr. Decker’s situation requires all health plans to provide some coverage to cater for diabetes care. However, this policy does not specify the services that these providers should provide (Myerson & Laiteerapong, 2016). The policy may help poor families if it requires coverage to ensure follow-up to ensure every diabetic elderly patient takes insulin as directed by the physician. A combination of strategies may help, including home care with support from a social worker, coordination by various health professionals, and use of electronic health records.

Strategy for Gathering Additional Necessary Assessment

The physician can rely on other people who know Mr. Decker well, which is referred to as an informant report. It is also possible to use direct observation, which involves observing Mr. Decker undertaking various activities. An effective tool that can be used in obtaining this information is the InterRAI Comprehensive Assessment Tool recommended by Gray et al. (2018). The physician can also use various secondary verbal or written sources, including medical reports, hospital records, communication from care providers in the community, as well as investigation results. The Comprehensive Assessment Tool might be used in exploring particular conditions like, pressure, pain, nutrition, or injury.

Since Mr. Decker is aged, no single standard may be used to assess his condition, but the Comprehensive Geriatric Assessment can be more efficacious. This tool is useful in understanding the multidimensional complex care needs of elderly patients in the long- and short-term. It is imperative that multiple team members with particular skills are involved based on his needs. Similarly, it is important to take into account Mr. Decker’s situation by collecting information and cues, which is achieved through questioning close family members and observing him. The health professional should then process the information with the aim of understanding what he needs. Finally, it is fundamental to establish goals, take actions or perform interventions, and evaluate care outcomes.

Factors Most Likely To Affect Patient Outcomes

In the case of Mr. Decker, several factors might affect care outcomes or the quality of diabetic services provided. First, delays in following up on diabetes medication and presence of unmanaged comorbidities will worsen patient outcomes. For instance, his wound has taken long to heal because a physician did not attend to it properly. Another factor that will affect patient outcomes is the presence or lack of continuity of care. Continued care and availability of a professional to follow up on Mr. Decker’s health status will improve the care outcome.

The other factor that will influence patient outcomes is the availability of diabetes educational materials in the hospital and out-of-the hospital settings. If caregivers access these materials, the patient outcomes will improve. Another factor is the availability of nurses who can take care of Mr. Decker in his language and provide client centered care (Al-Alawi, Al Mandhari, & Johansson, 2019). The involvement of other professionals including dieticians will also improve patient outcomes. The patient has to receive diabetic medication between appointments, as this will also improve outcomes.

Specific Patient and Care Coordination Outcome Measures Related to Specific Accrediting Standards

In providing care for Mr. Decker, care coordination will be essential. For instance, it will be crucial to work with Medicare and insurance companies while conforming to the federal regulations. Health professionals should help patients get the best care by advocating for them and helping them understand the regulation requirements. The two organizations authorized to ensure that diabetes self-management training services comply with the required standards are the American Association of Diabetes Educators and the American Diabetes Association.

Accreditation standards applicable to Mr. Decker’s case include providing ongoing support that recognizes the preference of the patient (CDC, 2019), continued evaluation of diabetes self-management training programs to ensure quality improvement, and the collaboration of experts in promoting the welfare of the patient. It is also imperative to promote diabetes self-management training within and outside hospital settings (Powers et al., 2017). Thus, the measures of care coordination outcome include the ability to provide continued support and care, effectiveness of education to the patient and health professionals, and the extent to which health providers and professionals collaborate with the patient to achieve the best health outcomes.

Evidence-based Practices from the Literature Necessary to Implement a Plan of Care Successfully

Coordination of various Healthcare Professionals

One of the ways to implement the plan of care is integrating medical office staff including the medical assistant into the diabetes care team. Collaboration is essential in nursing practice and health care organizations. With proper training, these professionals will facilitate coordinated and planned care that will improve patient health. Similarly, the patient will have more time with professionals.

Electronic Medical Records

With these records, it will be possible to provide the best care to the patient. For instance, if Mr. Decker visits a health facility he has never visited before, the new physician will know immediately that he had an infection in his toe previously (Han et al., 2015).. This will help in finding out if there is a need to address problems besides diabetes. Updated records will improve overall patient care.

Home Health Care with Social Worker Support

In the case of Mr. Decker, home-based care is the most affordable option. However, there is a need to have a social worker to follow up on the issues facing the family that might influence health care provision. It is also imperative for the family to seek financial help for diabetes care as recommended by the National Institute of Diabetes and Digestive and Kidney Diseases (2019).

Medicare Savings Programs

Mr. Decker may seek additional financial support, which may necessitate paying Medicare premiums, coinsurance, or deductibles depending on his state. Nevertheless, the Department of Social Services will advise on his eligibility.

Benefits of a Multidisciplinary Approach to Patient Care that a Care Coordination Plan Would Foster

A multidisciplinary approach will be essential in Mr. Decker’s case as it helps in integrating care in the support and social services. The patient will get help from a multi-disciplinary team that will ensure safe and early discharge to home and overcome barriers to the provision of care (Hegarty, Buckley, Forrest & Marshall, 2016). Overall, the health of the patient will improve with the use of a multidisciplinary approach.

Conclusion

Mr. Decker will benefit from a multidisciplinary approach that incorporates home care with support from a social worker, collaboration of various health professionals, and use of electronic health records. These records will help in improving care because different healthcare facilities and professionals can have information regarding the patient without wasting time. Coordination will help in providing the best care to the patient. Overall, the use of a multidisciplinary approach will help overcome the current gaps in the diabetes care policy.

References

• Al-Alawi, K., Al Mandhari, A., & Johansson, H. (2019). Care providers’ perceptions towards challenges and opportunities for service improvement at diabetes management clinics in public primary health care in Muscat, Oman a qualitative study. BMC health services research, 19(1), 18.
• Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Fischl, A. H., … & Vivian, E. (2017). Diabetes self-management education and support in type 2 diabetes a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. The Diabetes Educator, 43(1), 40-53.
• CDC. (2019). Standard 8 – Ongoing Support | National Standards for DSMES | DSMES Toolkit | Diabetes | CDC. Retrieved from https //www.cdc.gov/diabetes/dsmes-toolkit/standards/standard8.html
• Gray, L., Beattie, E., Boscart, V., Henderson, A., Hornby-Turner, Y., & Hubbard, R. et al. (2018). Development and Testing of the interRAI Acute Care A Standardized Assessment Administered by Nurses for Patients Admitted to Acute Care. Health Services Insights, 11, 117863291881883. doi 10.1177/1178632918818836
• Hegarty, C., Buckley, C., Forrest, R., & Marshall, B. (2016). Discharge Planning Screening Older Patients for Multidisciplinary Team Referral. International Journal of Integrated Care, 16(4), 1. doi 10.5334/ijic.2252
• Myerson, R., & Laiteerapong, N. (2016). The Affordable Care Act and Diabetes Diagnosis and Care Exploring the Potential Impacts. Current Diabetes Reports, 16(4). doi 10.1007/s11892-016-0712-z
• National Institute of Diabetes and Digestive and Kidney Diseases. (2019). Financial Help for Diabetes Care | NIDDK. Retrieved from https //www.niddk.nih.gov/health-information/diabetes/financial-help-diabetes-care
• Han, W., Sharman, R., Heider, A., Maloney, N., Yang, M., & Singh, R. (2015). Impact of electronic diabetes registry ‘Meaningful Use’on quality of care and hospital utilization. Journal of the American Medical Informatics Association, 23(2), 242-247.