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Assessment 2 Instructions: Quality Improvement Initiative Evaluation

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Deliver to the interprofessional team a presentation (20 minutes; 12-15 slides) that analyzes an existing workplace quality improvement initiative related to a specific disease, condition, or public health issue of interest. The presentation’s purpose is to inform and get buy-in from the interprofessional team.

Introduction

Too often, discussions about quality health care, care costs, and outcome measures take place in isolation—various groups talking among themselves about results and enhancements. Nurses are critical to the delivery of high-quality, efficient health care. As a result, they must develop their skills in reviewing and evaluating performance reports. They also need to be able to communicate outcome measures related to quality initiatives effectively. Patient safety and positive institutional health care outcomes mandate collaboration among nursing staff members to ensure the integration of their perspectives in all quality care initiatives.

In this assessment, you will have the opportunity to analyze a quality improvement initiative in your workplace. You will then present your analysis to a group of nurses and other health care professionals. The purpose of your presentation is to inform and enlist support for the initiative from your audience.

Preparation

Quality Initiative Selection

In this assessment you will deliver an analysis of an ongoing quality improvement initiative in your workplace. The initiative you analyze must relate to a specific disease, condition, or public health issue of personal or professional interest to you. The purpose of your analysis is to assess whether specific quality indicators point to improved patient safety, quality of care, cost and efficiency goals, and other desired metrics. Your audience consists of nurses and selected health care professionals with specializations or interest in your selected condition, disease, or issue. You hope to inform and garner support for the initiative from your audience.

Recording Your Presentation

To prepare to record a voice-over for your presentation:

Set up and test your microphone or headset using the installation instructions provided by the manufacturer. You only need to use the headset if your audio is not clear and high quality when captured by the microphone.

Practice using the equipment to ensure the audio quality is sufficient.

Consult Using Kaltura for guidance on how to record your presentation and upload it in the courseroom.

Microsoft PowerPoint also allows you to record your narration with your slides. If you choose this option, simply submit your presentation to the appropriate area of the courseroom. Your narration will be included with your slides.

Remember to practice delivering and recording your presentation multiple times to ensure effective delivery.

Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact Disability Services at DisabilityServices@Capella.edu to request accommodations.

Instructions

The optional QI Initiative Evaluation Presentation Template [PPTX] is provided to help you prepare your slides. Template is attached

In your presentation, you will:

Analyze a current quality improvement initiative in a health care or practice setting according to strategic organizational initiatives.

Explain the rationale behind the QI improvement initiative. What prompted the initiative?

Detail problems that were not addressed and any issues that arose from the initiative.

Evaluate the success of a current quality improvement initiative according to recognized national benchmarks.

Analyze the benchmarks used to evaluate success. Which aspects of the initiative were most successful? What outcome measures are missing or could be added?

Incorporate one appropriate supporting visual (such as a graph or chart) that showcases the most critical aspect of this presentation.

Incorporate interprofessional perspectives related to initiative functionality and outcomes.

Integrate the perspectives of interprofessional team members involved in the initiative. Who did you talk to? What are their professions? How did their perspectives impact your analysis?

Recommend additional indicators and protocols to improve and expand outcomes of a quality initiative.

Identify specific process or protocol changes as well as technologies that would improve quality outcomes.

Ensure slides are easy to read and error free. Provide detailed speaker notes. Also ensure audio is clear, organized, and professionally presented.

Organize content with clear purpose/goals and with relevant and evidence-based sources (published within 5 years).

Additional Requirements

Presentation length: A maximum of 20 minutes.

Number of slides: 12-15 slides. Balance text and visuals. Avoid text-heavy slides. Use speaker’s notes for additional content.

Font and font size: Appropriate size and weight for presentation, generally 24-28 point for headings; no smaller than 18 point for bullet-point text. Use a suitable professional typeface such as Times or Arial throughout the presentation.

Number of references: Cite a minimum of seven current scholarly and/or authoritative sources to support your analysis. Current is defined as no older than 5 years unless a seminal work.

APA formatting: Adhere to APA style and formatting guidelines for citations and references. Consult these resources for an APA refresher:

Evidence and APA.

APA Module.

American Psychological Association. (n.d.). APA style. https://www.apastyle.org/

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

Competency 2: Plan quality improvement initiatives in response to routine data surveillance.

Recommend additional indicators and protocols to improve and expand quality outcomes of a quality initiative.

Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.

Analyze a current quality improvement initiative in a health care or practice setting according to strategic organizational initiatives.

Evaluate the success of a current quality improvement initiative according to recognized national benchmarks.

Competency 4: Integrate interprofessional perspectives to lead quality improvements in patient safety, cost effectiveness, and work life quality.

Incorporate interprofessional perspectives related to initiative functionality and outcomes.

Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.

Slides are easy to read and error free. Detailed speaker notes are provided. Audio is clear, organized, and professionally presented.

Organize content with clear purpose/goals and with relevant and evidence-based sources (published within 5 years).

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Useful resources you can use

· Boytim, J., & Ulrich, B. (2018). 
Factors contributing to perioperative medication errors: A systematic literature review
AORN Journal: The Official Voice of Perioperative Nursing107(1), 91-107.

· Chatfield, J. S., Longenecker, C. O., Fink, L. S., & Gold, J. P. (2017). 
Ten CEO imperatives for healthcare transformation: Lessons from top-performing academic medical centers
Journal of Healthcare Management, 62(6), 371-383.

· Cookson, R., Asaria, M., Ali, S., Shaw, R., Doran, T., & Goldblatt, P. (2018). 
Health equity monitoring for healthcare quality assurance
Social Science and Medicine, 198, 148-156.

· Corrigan, S., Kay, A., O’Byrne, K., Slattery, D., Sheehan, S., McDonald, N., Smyth, D., Mealy, K., & Cromie, S. (2018). 
A socio-technical exploration for reducing & mitigating the risk of retained foreign objects
International Journal of Environmental Research and Public Health, 15(4), 714.

· Downie, K., Cunningham, A., & Jafri, M. (2021). 
Nurse-driven universal concussion screening.
 Journal of Trauma Nursing, 28(1), 67-72.

. This resource explores how quality initiatives are applied in clinical settings.

· Joint Commission. (2021). 
National Patient Safety Goals.
 https://www.jointcommission.org/standards_information/npsgs.aspx

· Li, J., Talari, P., Kelly, A., Latham, B., Dotson, S., Manning, K., Thornsberry, L., Swartz, C., & Williams, M. V. (2018). 
Interprofessional teamwork innovation model (ITIM) to promote communication and patient-centered, coordinated care.
 BMJ Quality & Safety27(9), 700-709.

. This resource explores how quality initiatives are applied in clinical settings.

· Margaryan, A., Littlejohn, A., & Stanton, N. A. (2017). 
Research and development agenda for learning from incidents
Safety Science, 99, Part A, 5-13.

· Mottes, T. A., Goldstein, S. L., & Basu, R. K. (2019). 
Process based quality improvement using a continuous renal replacement therapy dashboard.
 BMC Nephrology, 20(1), 1-10.

. This resource explores how quality initiatives are applied in clinical settings.

·
National Committee for Quality Assurance.
 (2020). http://www.ncqa.org/

. This database provides recognized benchmarks for quality indicators.

·
Nursing Masters (MSN) Research Guide
.

. You may wish to conduct additional independent research as you prepare for Assessment 2. This guide can help direct you to appropriate, credible, and valid resources.

· O’Donoghue, S. C., DiLibero, J., & Altman, M. (2021). 
Leading sustainable quality improvement.
 Nursing Management, 52(2), 42-50.

· Pitocco, C., Sexton, T. R., & Stickle, K. (2020). 
Using data analytics to improve hospital quality performance.
 Journal of Healthcare Management, 65(4), 285-298.

. This resource explores how quality initiatives are applied in clinical settings.

· Twohig, P. A., Rivington, J. R., Gunzler, D., Daprano, J., & Margolius, D. (2019). 
Clinician dashboard views and improvement in preventative health outcome measures: A retrospective analysis.
 BMC Health Services Research, 19(1), 475-475.

. This resource explores how quality initiatives are applied in clinical settings.

· Wu, D. T. Y., Vennemeyer, S., Brown, K., Revalee, J., Murdock, P., Salomone, S., France, A., Clarke-Myers, K., & Hanke, S. P. (2019). 
Usability testing of an interactive dashboard for surgical quality improvement in a large congenital heart center.
 Applied Clinical Informatics, 10(5), 859-869.

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CU_Horiz_RGB Patient Care Plan

CU_Horiz_RGB Patient Care Plan

Name: Date:


Patient Identifier: Patient Medical Diagnosis:

Nursing Diagnosis
Assessment Data

Goals and Outcome

Nursing Interventions

Rationale

Outcome Evaluation
and Re-planning

Include 3–5 pieces of data (subjective, objective, or a combination) that led to a nursing diagnosis.

Write two goal statements for each nursing diagnosis. Goals must be patient- and family-focused, measurable, attainable, reasonable, and time-specific.

List at least three nursing or collaborative interventions; provide the rationale for each goal and outcome.

Explain why each intervention is indicated or therapeutic; cite applicable references that support each intervention.

Were the goals met? How would you revise the plan of care according the patient’s response to the current plan of care? Support your conclusions with outcome measures and professional standards.

1

1

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PATIENT INFORMATION

Patient Name: Rebecca Snyder
DOB: 04/24/1953
Address: 1375 Cadburry Lane,
St. Louis Park MN 55402

Patient ID: #6700891
Gender: Female
Phone: (612) 776-8900

Insurance: Medicare
Primary Care Provider: Dr. Vereen, Vila
East

Contact Permissions:
David Snyder, husband (952) 493-9302
Avi Snyder, son (952) 783-0021

Patient ID: #6700891
Gender: Female
Phone: (612) 776-8900

PATIENT HISTORY

H&P: Mrs. Snyder is a 56 year old obese Orthodox Jewish women with a PMH
of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She
admits to the ED with c/o hyperglycemia ranging from 230 to 389 for over 10 days,
frequent urination, malaise, and mild abdominal discomfort, dyspnea on exertion
and HTN on admission.

Family Hx.
Mother: Alive. History of HTN, DM, Dementia.
Father: Deceased. HX of MI, Colorectal CA
Sister: Alive. HX of Breast CA. s/p right mastectomy.

Meds on Adm: Metformin 1000 mg q hs., Lisinopril 20 mg QD. Prior to adm. Was
prescribed anti-anxiety medication but self d/c’d without taper due to c/o fatigue.
V/S: 36.7, 102, 171/93, 24. O2 Saturations 92%. On room air.

Neuro: A&O x3. Appropriate responses, anxious. c/o daily H/A with minimal relief
with NSIADS. Recent c/o blurred vision. Wears glasses.

Cardio: HRR. Tachycardic. No audible murmurs or c/o CP. EKG normal.

Respiratory: Lung sounds diminished in all fields. Sats 92% on RA. c/o dyspnea on
exertion for 6 weeks. See for care at Ferndale clinic. Occasionally sleeps in reclining
chair at hs. Obtain CXR.

GU: c/o frequent urination. Per pt. menses have not yet ceased. Menses irregular.
Occasional vaginal bleeding duration: 1-2 days.

GI: c/o constipation and abd fullness. Abd. Tenderness on exam. + mild acites.
Palpated pelvic mass. c/o tenderness.

POC: CBC, BMP, blood glucose ac/hs.
CXR, abd. Ultraound. V/S q 4 hr. Metoprolol 25 mg Q 4 hours for BP over 170/80.
Initiate insulin gtt at 2u/hr. Blood glucose check q 1 hr. Consider paracentesis.

ALLERGIES & MEDICATION

Allergies: Sulfa

Medication: #6700891
Metformin 1000 mg po q hs for diabetes
Lisinopril 20 mg po qd for hypertension
Prosac 20 mg po BID (per pt., self d/c’d due to fatigue)
Xanax 0.25 prn anxiety hypercholesterolemia.
Pravastatin 40 mg po bid for hypercholesterolemia.
Advil 1 tab qd pain

LAB

CBC:
RBC: 5.1 HCT: 38.8
HGB: 14.7
WBC: 11.1
MCV: 81
MCH: 31
PLT: 301

BMP:
Glucose: 399
BUN: 15
CR: 1.1
Sodium: 138
Potassium: 4.2
Chloride: 106
Co2: 23
Calcium: 11
Protein: 7.9
CA-125-1700 U

PRIMARY CARE NOTES

05/10/19:
Abd CT showed multiple liver mass nodules too many to count. Suspected liver
metastasis
Colonoscopy showed a 3.1 cm colorectal mass. Invading lower intestine.
MRI negative for spinal cord or brain lesions.
Plan of care: Gynecologic oncology consult.
CBC, BMP, CA-125, HCG, AFP, Paracentesis, in am. PT, SW, CM consult.

05/09:
Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly
controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the
ED with c/o hyperglycemia over 230 for over 10 days, frequent urination, malaise,
mild abdominal discomfort, dyspnea on exertion.

DX: Hyperglycemia, abd. distention & acites, suspected ovarian cancer
Called Dr. Hanson-GYN ONC. Consult expected for tomorrow. Suggested CA-124,
HCG, AFP prior to consult.

Blood glucose 200 on insulin gtt. POC: d/c Insulin gtt. Begin 30 units of Lantis 1 x a
day in am and 10 mg. of Novalog 3 times a day.

05/09:
Abd. ultrasound approximately 450 ml of peritoneal fluid. Paracentesis is
recommended.

SOCIAL WORK

05/10:
Met with Mrs. Snyder on 05/09/19. Mrs. Snyder is a 56 year old obese Orthodox
women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety,
and obesity. She admits to the ED with c/o hyperglycemia over 230 for over 10 days,
frequent urination, malaise, mild abd. Discomfort, dyspnea on exertion.

On 05/08/19 pt. was diagnosed with Ovarian Cancer. Work-up still in progress to
determine stage, although it appears that Mrs. Snyder may have a Stage III or Stage IV
ovarian cancer. In addition, Mrs. Snyder has uncontrolled diabetes with blood glucose
levels consistently in the 200-300’s. PTA, she was on oral anti-diabetic medication. Will
most likely be d/c’d on insulin ac/hs. Will need diabetic teaching, glucose monitoring
and support.

Social:
Patient lives in a multi-level home with first floor set-up. Resides with husband, 2 teen
age children and is primary caregiver for elderly mother with dementia. Independent in
ADL’s. Able to walk household distances without AD but requires frequent rest breaks
due to fatigue and SOB. Family responsibilities include child care (2 teenage boys) total
physical care for elderly mother with dementia, shopping, meal preparation, cleaning,
as well as managing the home and business finances. Husband available, however just
opened a deli and is unable to assist with household duties.

Mrs. Snyder primary concern is the care for her mother. She has a sister that lives in
Florida, but she has not stepped up the plate or offer to care for their mother. Mrs.
Snyder has adult children. Her daughter may be of some help, however, she has 2 small
children to care for while her spouse works full time. Her son, Avi lives nearby, but she
does not believe that he would be able to manage her mothers’ care due to substance
abuse issues. Plan: Continue to meet with Mrs. Snyder and discuss discharge options.
Discuss case with care coordinator and primary care provider.

05/10:
Second visit with Mrs. Snyder to discuss new dx. of ovarian cancer Family member in
the room. Patient quiet. Pt. described tx options provided by GYN/ONC. Pt. fearful of
pain and discomfort of surgery and stated that she didn’t see that surgery would help
her much. Is willing to learn about additional options other than surgery. Pt. became
tearful when discussing the side effects of chemotherapy. “I don’t want to be in pain. I
certainly don’t want to feel nauseous! I just want to go home! Why can’t I go home?”
SW provided support and counseling. Session d/c’d after patient asked SW to leave.

CASE MANAGEMENT

Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly
controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the
ED with c/o hyperglycemia. C/O frequent urination, malaise, mild abd. Discomfort,
dyspnea on exertion. Reviewed notes from SW and appreciate team input.

Mrs. Snyder has been newly diagnosed with Stage IV ovarian cancer. She has a
large family and circle of friends but desires to manage on her own. Her primary
concern is the care of her elderly mother who requires total physical care. Listened
to concerns about surgery and chemotherapy. Educated patient regarding potential
side effects and what to expect. Answered questions about Radiation. In Ovarian
cancer, it is used means of combating pain and involves high energy rays, similar to
X-Rays, delivered to affected parts of the body.

DIABETES EDUCATOR

Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly
controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the
ED with c/o hyperglycemia over 230 for over 10 days, frequent urination, malaise,
mild abd. Discomfort, dyspnea on exertion.

Previously on Metformin only. Will most likely be d/c on Insulin BID with SSI ac.

Met with patient to discuss dietary needs and restrictions. Mrs. Snyder keeps
a kosher household. Family members are lactose intolerant, have nut allergies,
and her mother needs to have her meals pureed due to cognitive difficulties that
impact her nutritional status. Pt. prepares meals and shops for the family. Pt. makes
traditional meals such as roast beef, kugel, and potatoes. Occasional fresh greens,
but the majority of fruits and vegetables are canned. Pt. admits to snacking on
popped corn salty chips and enjoys chocolate cookies at bedtime.

Plan of Care: Provided Mrs. Snyder with diabetic resources. Diabetic diet and
insulin teaching. Would benefit from diabetic nutritional counselling at d/c. Diabetic
teaching initiated.

REHAB

Initial-Consult: 05/10
Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly con-
trolled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED
with c/o hyperglycemia over 230 for over 10 days, frequent urination, malaise, mild
abd. Discomfort, dyspnea on exertion.

Lives in a multi-level house with 8 STE. One flight of steps to second level. Bed and
bath on 2nd level with first floor set up available. Resides with husband, elderly
mother and 2 teenage sons.

Independent in ADL’s. Requires additional time due to fatigue and recent SOB.

Household duties include: walking household distances, shopping, meal prepara-
tion, cleaning, driving, and providing total care to elderly mother, managing busi-
ness and personal finances.

Pt. able to ambulate 50’ without AD, but required HHA due to c/o feeling unsteady.
Required seated rest breaks x4 due to c/o SOB and fatigue. Pulse oximeter 91%
with ambulation. Returned to chair with pulse oximeter to 92%. In no distress.

Bed to chair transfer: Independent
Toilet transfer: Independent.13 steps with frequent rest breaks.
Steps: Patient able to ascent/descend
LTG: Pt. will walk 200’ without AD independently.
STG: Pt. will walk 50’ without seated rest break.

PROGRESS NOTES

Given patient s/s, suspect Ovarian Cancer. Appreciate Gynecologic oncologist
consult. To discuss options with patient. Surgery may be an option, however, due to
her having stage IV, supportive care, pain and symptom management is more likely
through chemotherapy and radiation.

GYN/ONC

Mrs. Snyder is a 56 year old Orthodox women with a PMH of poorly controlled DM,
HTN, anxiety, and obesity. She admits to the ED with c/o hyperglycemia over 230
for over 10 days, malaise, and mild abd. Discomfort. Her initial exam revealed and
enlarged abd. with pelvic mass. GYN/ONC physical exam: palpable bilateral ovaries
with size consistent with radiology.

Radiologic studies revealed:
05/09/19: Abd. Ultrasound approximately 450 ml of peritoneal fluid. Paracentesis is
recommended for comfort and disease staging.
05/09/19: Abd CT showed multiple liver mass nodules too many to count.
Suspected liver metastasis
05/10/19: Colonoscopy showed a 3.1 cm colorectal mass. Invading lower intestine.
05/10/19: MRI negative for spinal cord or brain lesions.

Blood work:
CA-125-1500 U/ml
human chorionic gonadotropin (HCG): 6241
alpha-fetoprotein (AFP): 997
Paracentecis lactate dehydrogenase (LDH): Above normal @ 480U/L

Based on physical presentation, blood work and radiology studies, Ovarian
Cancer is confirmed. Discuss with pt. treatment options such as surgery and/or
Chemotherapy and radiation. Thank you for allowing me to consult on Mrs. Snyder.

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Quality Improvement Initiative Evaluation: Assessment 2:
Add the Title of the QuaIity Improvement Initiative

Add your name

MSN-FPX6016

Add the Date

1

Analysis of Quality Improvement Initiative: Part 1

Organization’s Strategic Initiatives

Rationale Supporting the Quality Improvement Initiative

2

Analysis of Quality Improvement Initiative: Part 2

The Importance of the Quality Improvement Initiative

Specific Implications of the Quality Improvement Initiative

3

Evaluation of the Quality Improvement Initiative

National Benchmarks Supporting the Quality Improvement Initiative

Analysis of the Benchmarks Related to the Quality Improvement Initiative

4

Evaluation of the Quality Improvement Initiative

Successful Quality Improvement Initiative Outcomes

Additions to the Quality Improvement Initiative

5

Critical Aspects of the Quality Improvement Initiative

Add your visual here

6

Interprofessional Team

Interprofessional Team Members Involved in the Quality Improvement Initiative

Team Member Perspectives

Impact of Team Member Perspectives on the Quality Improvement Initiative

7

Recommendations for the Future: Part 1

Additional Indicators to Expand Knowledge of Quality

New Technology to Enhance Outcomes

8

Recommendations for the Future: Part 2

New Protocols to Enhance Quality

9

Questions

Thank you for participating today!

10

References

Add the references here

11

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Care Coordination Scenario I

·
Introduction

·
Challenge Details

·
New Case Email

·
Electronic Health Record

·
Patient Interview

·
Family Interviews

·
Case Strategy Email

·
Case Strategy Meeting

·
Case Strategy Meeting Recap Email

·
Conclusion

Introduction

Care coordination is like a puzzle. Every patient has a unique set of medical, social, and cultural considerations. It’s up to the care coordination team to problem solve and figure out the best course of action for each patient. In this activity, the care coordinator is presented with one such “puzzle”: a patient who has specific family and religious concerns.

After completing the activity, you will be prepared to:

· Investigate a care coordination plan of action for a complex case that involves medical, social, and cultural considerations.

· Apply current health care standards to a care coordination scenario.

Challenge Details

Rebecca Snyder, 56, is the matriarch of a traditional Orthodox Jewish family. She is the mother of five, including two teenagers at home, and the grandmother of seven. She was brought into the emergency room at St. Anthony Medical Center last week with uncontrolled diabetes and hyperglycemia. The doctors discovered other problems, and unfortunately Mrs. Snyder was diagnosed with advanced ovarian cancer.

As a part of your care coordination internship at St. Anthony Medical Center, you are assigned to Mrs. Snyder’s case. Because she is the primary caregiver in her family, she and her family are especially ill-prepared for this serious diagnosis. You will be responsible for investigating this situation and for helping Mrs. Snyder and her family get the care and support they need.

New Case Email

Everyone is impressed with how well you’re doing as an intern! We’ve decided to assign you a more complicated case. The patient’s name is Rebecca Snyder. She’s 56 years old and was recently diagnosed with ovarian cancer and admitted to SAMC for uncontrolled diabetes and hyperglycemia. She’s medically stable to be released, and ready to start chemo and radiation on an out-patient basis.. However, there are some potential red flags in this case. Mrs. Snyder is the primary caregiver to her husband, children, and her elderly mother. She has not been treating her diabetes sufficiently.

First, read through Mrs. Snyder’s electronic medical record carefully. Then, you’ll want to meet with Mrs. Snyder as soon as possible.

This may be a tough case, but I know you’re up for it. Let me know if you need any help. Good luck!

Thanks,
Denise

Electronic Health Record

Patient Information

Patient Name: Rebecca Snyder
DOB: 04/24/1953
Address: 1375 Cadburry Lane, St. Louis Park MN 55402

Patient ID: #6700891
Gender: Female
Phone: (612) 776-8900

Insurance: Medicare
Primary Care Provider: Dr. Vereen, Vila East

Contact Permissions:
David Snyder, husband (952) 493-9302
Avi Snyder, son (952) 783-0021

Patient History

H&P: Mrs. Snyder is a 56 year old obese Orthodox Jewish women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia ranging from 230 to 389 for over 10 days, frequent urination, malaise, and mild abdominal discomfort, dyspnea on exertion and HTN on admission.

Family Hx.
Mother: Alive. History of HTN, DM, Dementia.
Father: Deceased. HX of MI, Colorectal CA
Sister: Alive. HX of Breast CA. s/p right mastectomy.

Meds on Adm: Metformin 1000 mg q hs., Lisinopril 20 mg QD. Prior to adm. Was prescribed anti-anxiety medication but self d/c’d without taper due to c/o fatigue.
V/S: 36.7, 102, 171/93, 24. O2 Saturations 92%. On room air.

Neuro: A&O x3. Appropriate responses, anxious. c/o daily H/A with minimal relief with NSIADS. Recent c/o blurred vision. Wears glasses.

Cardio: HRR. Tachycardic. No audible murmurs or c/o CP. EKG normal.

Respiratory: Lung sounds diminished in all fields. Sats 92% on RA. c/o dyspnea on exertion for 6 weeks. See for care at Ferndale clinic. Occasionally sleeps in reclining chair at hs. Obtain CXR.

GU: c/o frequent urination. Per pt. menses have not yet ceased. Menses irregular. Occasional vaginal bleeding duration: 1-2 days.

GI: c/o constipation and abd fullness. Abd. Tenderness on exam. + mild acites. Palpated pelvic mass. c/o tenderness.

POC: CBC, BMP, blood glucose ac/hs.
CXR, abd. Ultraound. V/S q 4 hr. Metoprolol 25 mg Q 4 hours for BP over 170/80.
Initiate insulin gtt at 2u/hr. Blood glucose check q 1 hr. Consider paracentesis.

Allergies & Medication

Allergies: Sulfa

Medication: #6700891
Metformin 1000 mg po q hs for diabetes
Lisinopril 20 mg po qd for hypertension
Prosac 20 mg po BID (per pt., self d/c’d due to fatigue)
Xanax 0.25 prn anxiety hypercholesterolemia.
Pravastatin 40 mg po bid for hypercholesterolemia.
Advil 1 tab qd pain

Lab

CBC:
RBC: 5.1 HCT: 38.8
HGB: 14.7
WBC: 11.1
MCV: 81
MCH: 31
PLT: 301

BMP:
Glucose: 399
BUN: 15
CR: 1.1
Sodium: 138
Potassium: 4.2
Chloride: 106
Co2: 23
Calcium: 11
Protein: 7.9
CA-125-1700 U

Primary Care Notes

05/13/19:
Abd CT showed multiple liver mass nodules too many to count. Suspected liver metastasis
Colonoscopy showed a 3.1 cm colorectal mass. Invading lower intestine.
MRI negative for spinal cord or brain lesions.
Plan of care: Gynecologic oncology consult.
CBC, BMP, CA-125, HCG, AFP, Paracentesis, in am. PT, SW, CM consult.

05/12/19:
Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia over 230 for over 10 days, frequent urination, malaise, mild abdominal discomfort, dyspnea on exertion.

DX: Hyperglycemia, abd. distention & acites, suspected ovarian cancer
Called Dr. Hanson-GYN ONC. Consult expected for tomorrow. Suggested CA-124, HCG, AFP prior to consult.

Blood glucose 200 on insulin gtt. POC: d/c Insulin gtt. Begin 30 units of Lantis 1 x a day in am and 10 mg. of Novalog 3 times a day.

05/12/19:
Abd. ultrasound approximately 450 ml of peritoneal fluid. Paracentesis is recommended.

Social Work

05/13/19:
Met with Mrs. Snyder on 4/19/2015. Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia over 230 for over 10 days, frequent urination, malaise, mild abd. Discomfort, dyspnea on exertion.

On 05/11/19 pt. was diagnosed with Ovarian Cancer. Work-up still in progress to determine stage, although it appears that Mrs. Snyder may have a Stage III or Stage IV ovarian cancer. In addition, Mrs. Snyder has uncontrolled diabetes with blood glucose levels consistently in the 200-300’s. PTA, she was on oral anti-diabetic medication. Will most likely be d/c’d on insulin ac/hs. Will need diabetic teaching, glucose monitoring and support.

Social:
Patient lives in a multi-level home with first floor set-up. Resides with husband, 2 teen age children and is primary caregiver for elderly mother with dementia. Independent in ADL’s. Able to walk household distances without AD but requires frequent rest breaks due to fatigue and SOB. Family responsibilities include child care (2 teenage boys) total physical care for elderly mother with dementia, shopping, meal preparation, cleaning, as well as managing the home and business finances. Husband available, however just opened a deli and is unable to assist with household duties.

Mrs. Snyder primary concern is the care for her mother. She has a sister that lives in Florida, but she has not stepped up the plate or offer to care for their mother. Mrs. Snyder has adult children. Her daughter may be of some help, however, she has 2 small children to care for while her spouse works full time. Her son, Avi lives nearby, but she does not believe that he would be able to manage her mothers’ care due to substance abuse issues. Plan: Continue to meet with Mrs. Snyder and discuss discharge options. Discuss case with care coordinator and primary care provider.

05/13/19:
Second visit with Mrs. Snyder to discuss new dx. of ovarian cancer Family member in the room. Patient quiet. Pt. described tx options provided by GYN/ONC. Pt. fearful of pain and discomfort of surgery and stated that she didn’t see that surgery would help her much. Is willing to learn about additional options other than surgery. Pt. became tearful when discussing the side effects of chemotherapy. “I don’t’ want to be in pain. I certainly don’t want to feel nauseous! I just want to go home! Why can’t I go home?” SW provided support and counseling. Session d/c’d after patient asked SW to leave.

Case Management

Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia. C/O frequent urination, malaise, mild abd. Discomfort, dyspnea on exertion. Reviewed notes from SW and appreciate team input.

Mrs. Snyder has been newly diagnosed with Stage IV ovarian cancer. She has a large family and circle of friends but desires to manage on her own. Her primary concern is the care of her elderly mother who requires total physical care. Listened to concerns about surgery and chemotherapy. Educated patient regarding potential side effects and what to expect. Answered questions about Radiation. In Ovarian cancer, it is used means of combating pain and involves high energy rays, similar to X-Rays, delivered to affected parts of the body.

Diabetes Educator

Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia over 230 for over 10 days, frequent urination, malaise, mild abd. Discomfort, dyspnea on exertion.

Previously on Metformin only. Will most likely be d/c on Insulin BID with SSI ac.

Met with patient to discuss dietary needs and restrictions. Mrs. Snyder keeps a kosher household. Family members are lactose intolerant, have nut allergies, and her mother needs to have her meals pureed due to cognitive difficulties that impact her nutritional status. Pt. prepares meals and shops for the family. Pt. makes traditional meals such as roast beef, kugel, and potatoes. Occasional fresh greens, but the majority of fruits and vegetables are canned. Pt. admits to snacking on popped corn salty chips and enjoys chocolate cookies at bedtime.

Plan of Care: Provided Mrs. Snyder with diabetic resources. Diabetic diet and insulin teaching. Would benefit from diabetic nutritional counselling at d/c. Diabetic teaching initiated.

Rehab

Initial-Consult: 05/13/19
Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia over 230 for over 10 days, frequent urination, malaise, mild abd. Discomfort, dyspnea on exertion.

Lives in a multi-level house with 8 STE. One flight of steps to second level. Bed and bath on 2nd level with first floor set up available. Resides with husband, elderly mother and 2 teenage sons.

Independent in ADL’s. Requires additional time due to fatigue and recent SOB.

Household duties include: walking household distances, shopping, meal preparation, cleaning, driving, and providing total care to elderly mother, managing business and personal finances.

Pt. able to ambulate 50′ without AD, but required HHA due to c/o feeling unsteady. Required seated rest breaks x4 due to c/o SOB and fatigue. Pulse oximeter 91% with ambulation. Returned to chair with pulse oximeter to 92%. In no distress.

Bed to chair transfer: Independent
Toilet transfer: Independent.13 steps with frequent rest breaks.
Steps: Patient able to ascent/descend
LTG: Pt. will walk 200′ without AD independently.
STG: Pt. will walk 50′ without seated rest break.

Progress Notes

Given patient s/s, suspect Ovarian Cancer. Appreciate Gynecologic oncologist consult. To discuss options with patient. Surgery may be an option, however, due to her having stage IV, supportive care, pain and symptom management is more likely through chemotherapy and radiation.

GYN/ONC

Mrs. Snyder is a 56 year old Orthodox women with a PMH of poorly controlled DM, HTN, anxiety, and obesity. She admits to the ED with c/o hyperglycemia over 230 for over 10 days, malaise, and mild abd. Discomfort. Her initial exam revealed and enlarged abd. with pelvic mass. GYN/ONC physical exam: palpable bilateral ovaries with size consistent with radiology.

Radiologic studies revealed:
05/12/19: Abd. Ultrasound approximately 450 ml of peritoneal fluid. Paracentesis is recommended for comfort and disease staging.
05/12/19: Abd CT showed multiple liver mass nodules too many to count. Suspected liver metastasis
05/13/19: Colonoscopy showed a 3.1 cm colorectal mass. Invading lower intestine.
05/13/19: MRI negative for spinal cord or brain lesions.

Blood work:
CA-125-1500 U/ml
human chorionic gonadotropin (HCG): 6241
alpha-fetoprotein (AFP): 997
Paracentecis lactate dehydrogenase (LDH): Above normal @ 480U/L

Based on physical presentation, blood work and radiology studies, Ovarian Cancer is confirmed. Discuss with pt. treatment options such as surgery and/or Chemotherapy and radiation. Thank you for allowing me to consult on Mrs. Snyder.

Patient Interview

You now know more about Mrs. Snyder’s case and can start assessing her situation. Refer back to her electronic medical record at any time if you need more information. Now, you should meet with Mrs. Snyder and ask her some questions.

Rebecca Snyder

Patient

1. How are you feeling today, Mrs. Snyder?

Rebecca: Oy, I’ve been better, I guess! The pain medication is making me very sleepy. But it’s controlling the pain. So I guess I can stand it for now. But when I go home I’m not going to be able to be this out of it. Mostly I’m just worried sick about my family. I’m the one who takes care of everything. And I mean everything—the cooking, the cleaning, the dogs, rides to baseball practice for my sons… and my mother too. She lives with us, and I take care of her because she’s not well. I just want to go home so I can take care of everything like I’m supposed to!

2. Can you tell me about your family situation?

Rebecca: Well, David is my husband. We’ve been married for 36 years now! He used to be an accountant, but last year he finally took the plunge and bought his own deli. His dream come true. It’s going ok, but it’s a lot of work, and sometimes I don’t see him all day because he’s working. And we have five children. Two of them are at home—my twin boys Eli and Isaac. They’re 14 and they’re really great kids… they’re both on the baseball team and all kinds of activities, and I feel like I spend half my life driving them places. And also taking care of their dogs… oy. We never had dogs before, but the twins just begged us for years, so we got them two great big Golden Retrievers. The deal was that they were supposed to take care of the dogs, but you can imagine how that went!

Then we have three grown kids. Our oldest son Oren lives in New Jersey and we don’t see him enough. He’s married and has four children. Our daughter Devorah lives close by and I see her every day. She has two beautiful little girls and she’s a little overwhelmed, so I help her out as much as I can. And our other son, Avi… oy, he’s a handful! He has a little boy and just split up from his lovely wife, which I keep telling him is a terrible idea, but why would he listen to his mother? My husband made him the assistant manager of the deli, and that’s been an absolute disaster—especially because, well, I hope I’m not telling you too much, but he has a drinking problem. That boy needs to learn some responsibility fast. The other member of my household is my mother, who’s 87 years old and not in good health. She was doing fine on her own until a few years ago, but now the dementia is getting worse and she just can’t be alone anymore.

3. Is there someone at home who can help take care of you?

Rebecca: Take care of me? Now that would be a change. I mean, I don’t want to complain. We’re a very traditional family when it comes to women’s work and men’s work. And that was completely my choice. I actually wasn’t raised Orthodox. My family was somewhat observant, but not the way we are—we didn’t keep kosher growing up, and my mother worked as soon as we were in elementary school. I met David at a dance, and that was that. I married him and became Orthodox. So I chose this lifestyle and the traditional gender roles that come with it. I couldn’t imagine it any other way. So no, there’s no one who can take care of me, not really. David, he’s a good man and he’ll do what he can, but he’s been working 15-hour days lately! I’m sure my daughter can help me with medication and things like that, but she’s so busy with her kids that I don’t want to burden her. We do have neighbors and friends from our synagogue…I’m sure they’ll be sending us meals and looking in on me, just like I’ve done for lots of other people over the years.

4. How is your home set up? Do you have to walk up and down stairs often?

Rebecca: Outside, it’s not a problem. There’s only one step up into the house. But we do have a lot of stairs inside. David and I used to sleep in the first floor bedroom suite. But then when my mother moved in, we moved into a bedroom upstairs. She uses a walker and there’s no way we could move her into any other bedroom.

5. How are things going with your diabetes?

Rebecca: I know… I really need to control my diabetes better. I put on all this weight when I had the twins and I’ve been gaining and losing the same 15 pounds for years, but I just can’t seem to get it off. I run around so much, you’d think that would help… I mean, I walk those dogs twice a day most of the time! But it’s just so hard to eat right… and I know, I use food as a crutch when I get stressed out about my son Avi and stuff like that, which happens pretty much all the time! And I know it would be good for all of us to make changes in our diet, but that’s not easy. My husband is the pickiest eater and my mother can only eat certain things, and three of my kids are lactose intolerant, and now it turns out my baby granddaughter who’s at my house every day has a nut allergy! And on top of all that I need to maintain a strict kosher household. There’s too many food requirements already for me to add my diabetes to the list.

6. How do you feel about chemo and radiation?

Rebecca: I don’t know. To be honest, I’m worried sick about the pain and the nausea. I’m terrible with pain! With all my kids, I wasn’t going to have an epidural, but every single time I wimped out pretty much immediately. I kind of wonder if I should go back on anti-anxiety pills, because I’m really upset about this… but I’m worried those will make me really sleepy, which is why I stopped taking them.

But the thing is, my doctor says the chemo and radiation could prolong my life by a couple of years potentially. Maybe even more. I know a number of people who were supposed to die of cancer right away and they hung on for years! So that’s what I need to do, right? (tears up) My family needs me. I’m honestly more scared about what’s going to happen to my family when I’m gone. God will take care of me, but who’s going to walk the dogs?

7. What questions do you have for me?

Rebecca: I’m so worried about my mother. Can you… I don’t know if it’s part of what you do, but can you help me figure out what to do about her? I was determined to keep her out of a home no matter what, and I still feel that way. But what if I can’t take care of her anymore? My sister lives in Florida and I guess she could take her in, but I don’t want to send my mother so far away when we’re her main support system…and anyway, I frankly don’t think my sister has the patience to handle my mother’s health problems. It’s probably too much to ask, but if you could give me some advice about what to do for her…? This is really eating me up inside.

Family Interview

Hopefully you have a better sense of Mrs. Snyder’s situation. She’s tired now, so now it’s time to talk to some family members to see what insight they have about how to provide Mrs. Snyder about the care she needs. You only have time for one phone call right now.

David Snyder

Rebecca Synder’s Husband

1. Mr. Snyder, I have some questions for you about your wife’s care.

David: So you’re from the hospital? Is my wife okay? Oh good. MITCH! NO, PUT THAT DOWN! I’LL FINISH THAT ORDER! Okay. I’m sorry about that. I’m at my deli. Things are kind of crazy here today. MITCH! I SAID, I’LL FINISH THAT ORDER! GO WORK ON A DIFFERENT ORDER! I’m really sorry. You said you had some questions about my wife? Look, maybe you should call my daughter Devorah. I don’t know the first thing about taking care of someone with cancer. I can’t even tell you how overwhelmed I feel. If I had any idea she was going to get sick, I wouldn’t have opened this deli, that’s for sure. But it’s too late now… MITCH! PUT THAT VERKAKTE SANDWICH DOWN! I SAID I’LL FINISH THE ORDER! Look, like I said, I’m not good with this kind of thing and I’m completely overwhelmed. I don’t have any idea how we’re going to manage this. I’ll try to help though. What do you need to know?

2. Let’s rethink this decision.

Denise: I’m going to stop you right there. Clearly Mr. Snyder is distracted right now. You might want to talk with him later. But it also sounds like he’s really overwhelmed, and from what Mrs. Snyder said, he might not be the best person to talk to for insight about her care. Caregiving simply hasn’t been his role in the relationship. I recommend you call someone else.

Devorah Kaufman

Rebecca Synder’s Daughter


Your preceptor stops you before calling Mrs. Snyder’s daughter.

1. What’s Wrong?

Denise: I’m going to stop you right there. You can’t call Mrs. Snyder’s daughter. Refer back to Rebecca Snyder’s electronic medical record. There’s a list of people she’s given the hospital permission to speak with about her care. And there’s only two people on that list—her husband David and her son Avi. I know—based on what you know so far, that doesn’t make sense. Mrs. Snyder said that she was very close to her daughter. When she wakes up, you might want to ask her if she’d like to update the list so that you can talk to Devorah. In the meantime, you’ll have to talk to someone else.

Avi Snyder

Rebecca Synder’s Son

1. Mr. Snyder, I have some questions for you about your mother’s care.

Avi: Oh, I’m so glad you called! My father’s way too upset to talk about this right now, and frankly he doesn’t know the first thing about what my mom needs. My mother probably gave you this big spiel about what a no-goodnick son I am, didn’t she? Oh, never mind that. I know a lot more about what’s going on than my mother gives me credit. What questions do you have for me?

2. How is your mother feeling about her illness?

Avi: Well, you can imagine, she’s certainly not happy about it! For one thing, she’s worried sick about everyone else. She really does take care of everything in our family, and she likes it that way. On top of everything she does, she insists on taking care of my grandmother and keeping her out of a home. But she’s probably told you all of that. What she probably hasn’t told you is how scared she is about the chemo and the pain. I don’t think she’s particularly scared about death—I mean, more than any of us are—but she’s always been terrified of doctors and pain. I suspect she has a lower threshold for pain than most people. I know I do, and maybe that’s a genetic thing? Anyways, one thing my mom might not have told you is that she’s been off and on anti-anxiety meds for years, and unfortunately they make her really tired so she hasn’t been able to stay on them. And pain is one of her biggest fears. So I hope you and the doctors keep this in mind when you’re putting together a plan for

3. Is there anyone in the family who can help care for her?

Avi: Yeah… me! She’ll kick and scream because she thinks that’s a daughter’s role and that I’m a no-goodnik. But my sister isn’t in a position to help all that much. I mean, she’ll do what she can, but… well, okay, please don’t tell my mom this yet, but my sister thinks she might be pregnant again. So she’s already got two little girls under the age of four and possibly another one on the way, and she doesn’t seem to have easy pregnancies. So if she’s actually pregnant, she’s not going to be able to help all that much, and even if she’s not pregnant, she’s already overwhelmed with parenthood. But I can help. And my little brothers can help out too. She’s always complaining that they don’t do things like walk the dogs, but that’s because she doesn’t make them. They’re 14 years old and they’re perfectly capable of cleaning up after themselves and doing some of the cooking. Also, I’m sure my mother hasn’t said anything, but she has a sister who lives in Florida who will be more than willing to fly in and help. She and my Aunt Janet don’t get along all the time and I’m sure my mom doesn’t want to burden her, but Aunt Janet is retired and has plenty of money and would be on a plane in a minute if my mom would ask.

4. Can you describe the situation with your grandmother living in the home?

Avi: My Baubie needs to be in a nursing home. In my opinion, that should have happened six months ago, even before my mom’s cancer diagnosis. I admire my mother for taking on the role of caregiver, but there’s a point where it’s too much. When my grandmother started needing help bathing and feeding herself, that’s when she needed to move out, in my opinion. Also, my grandmother’s wandered out the front door by herself a few times. She hasn’t gone far and she hasn’t gotten lost, but I think there’s a good possibility that could happen.

5. How would your mother feel about a home health aide?

Avi: Oy! She’d kick and scream and tell us she can do it all herself. But she’d probably go for it eventually. The problem with that is that I don’t know if they could afford for someone to come in. When my dad was an accountant they had better insurance. But now that my dad quit and started his own deli, they’re covered by insurance through the Affordable Care Act. And thank God that’s available! But I don’t think it covers home health care, does it? That’s something we need help figuring out. Because the deli has been a huge financial burden for the family. Huge! It’s doing pretty well, but all businesses are slow at first, and there’s just not that much money coming in. And my mom has been adamant about not tapping into my brothers’ college funds for her health care. Ugh! I really don’t know what we’re going to do. I wish my mom were old enough for Medicare, but she’s only 56.

6. Do you think your mother would be open to help with her diabetes and nutrition?

Avi: Good luck with that! My sister and I have been on her case for years to start eating better and she won’t listen to us. And my father is absolutely no help. He’s the pickiest eater I know and goes nuts when my mother tries to make something more healthy. He insists that she make pies and cookies even though my mom has no willpower around those things, so they’re always in the house. And now that she has cancer, I know that a healthier diet would make things a little easier for her, but I just don’t see that happening. I see my mom just throwing in the towel and saying that she’s dying anyway and she should be able to eat whatever she wants.

7. Is there anything else you’d like us to know about your mother’s care?

Avi: My father is having a really hard time coping with this. He’s coping by working more, which is pretty much the opposite of what should be happening. My father is completely ill-equipped to deal with this situation, both emotionally and in terms of knowing how to be a caregiver. I wonder if there’s some kind of Jewish support group we could find for him. And no one wants to talk about this, but there’s a pretty good chance he’s going to be a single father to my little brothers. I think my mother thinks that Devorah’s going to raise them, but I don’t think she can handle that, especially if it turns out she’s pregnant again. Our family needs to have a serious conversation about that, but we’re not so great at communication.

Mrs. Snyder’s Case

It looks like you’ve gathered some helpful information about Mrs. Snyder’s case! Now it’s time to come up with a care coordination strategy. At this point, you’ll want to speak with a social worker to discuss next steps. I suggest you meet with Samantha Rockwell, as she’s experienced with complicated cases like this. I also suggest that you meet with Karen Wu to discuss nutritional issues. In addition, it can be very helpful to speak with an experienced case manager, especially since this is your first complicated case.

Best of luck,
Denise

Case Strategy Meeting

It looks like you’ll be listening in on a meeting. Let’s hear what your new colleagues have to say about this patient.

· Karn Wu, Dietition

· Samantha Rockwell, Social Worker

· Nora Jackson-Green

1. Do you think a home health care nurse is a viable solution?

Karen: I think that’s the best solution. It definitely sounds like Mrs. Snyder doesn’t have anyone who can take care of her to the degree to she needs. She needs to have a home health nurse working with her on her diabetes and to assess her for additional problems.

Samantha: That may be the case. But it sounds like they have financial concerns.

Nora: They have insurance under the Affordable Care Act. If home health care turns out to be the b

I need this by monday

Complete an interactive simulation that includes interviews of a patient, family members, and experienced health care workers. Then, develop a care coordination strategy and a care plan for the patient based on the information gathered from the interviews.

Introduction

Note: Each assessment in this course builds on your work from the preceding assessment; therefore, complete the assessments in the order in which they are presented.

Whether designing care plans directed by patients’ needs and preferences, educating patients and their families at discharge, or doing their best to facilitate continuity of care for patients across settings and among providers, registered nurses use accredited health care standards to realize coordinated care. This assessment provides an opportunity for you to explore health care standards with respect to the quality of care, investigate opportunities and challenges in care coordination, and develop a proactive, patient-centered care plan.

The National Strategy for Quality Improvement in Health Care (2011) focuses on improving patient care, maximizing health resources, and reducing preventable hospital readmissions. Care coordinators reduce readmissions of those suffering from chronic conditions (such as congestive heart failure, pneumonia, asthma, and diabetes) and are responsible for providing quality care in a fiscally responsible manner. While this may seem a reasonable task, shifting the way we use health care resources can be a challenge. Consequently, you must be cognizant of effective strategies for reducing preventable readmissions and understand the barriers that nurses face when coordinating care for patients with chronic illnesses.

Reference

Agency for Healthcare Research and Quality. (2011). 2011 report to Congress: National strategy for quality improvement in health care. AHRQ. https://www.ahrq.gov/workingforquality/reports/2011-annual-report.html

Note: Complete the assessments in this course in the order in which they are presented.

Preparation

As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.

· To what extent does a needs assessment support nursing diagnoses?

· Which standards or benchmarks drive outcomes in your current professional practice?

· What action might you take in response to care plan goals or outcomes that are not being met?

To prepare for this assessment, complete the following simulation:

·
Vila Health: Care Coordination Scenario I
.

In this simulation, you will obtain the information needed to develop a care coordination strategy for Mrs. Snyder and her family. You may use an intervention developed as part of your first assessment. Locate applicable current standards and benchmarks as you determine the best way to develop this strategy.

Note: Remember that you can submit all or a portion of your draft to Smarthinking for feedback before you submit the final version of this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.

Requirements

Develop a proactive, patient-centered care plan for the patient, using the information gained from your simulated interviews. Focus on care coordination and national care coordination initiatives.

Care Plan Format

Use the 
Patient Care Plan Template [DOCX]
 provided.

Supporting Evidence

Cite 3–5 sources of scholarly or professional evidence to support your plan.

Developing the Care Plan

The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your care plan addresses each point, at a minimum. Read the Patient Care Plan Scoring Guide to better understand how each criterion will be assessed.

· Assess a patient’s condition from a coordinated-care perspective.

. Consider the full scope of the patient’s needs.

. Include 3–5 pieces of data (subjective, objective, or a combination) that led to a nursing diagnosis.

· Develop nursing diagnoses that align with patient assessment data.

. Write two goal statements for each diagnosis.

. Ensure goals are patient- and family-focused, measurable, attainable, reasonable, and time-specific.

. Consider the psychosociocultural aspect of care.

· Determine appropriate nursing or collaborative interventions.

. List at least three nursing or collaborative interventions.

. Provide the rationale for each goal or outcome.

· Explain why each intervention is indicated or therapeutic.

. Cite applicable references that support each intervention.

· Evaluate care coordination outcomes according to measures and standards.

. Indicate if the goals were met. If they were not met, explain why.

. Describe how you would revise the plan of care based on the patient’s response to the current plan.

. Support conclusions with outcome measures and professional standards.

· Write clearly and concisely, using correct grammar and mechanics.

. Express your main points and conclusions coherently.

. Proofread your writing to minimize errors that could distract readers and make it difficult to focus on the substance of your plan.

· Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.

Portfolio Prompt: You may choose to save your patient care plan to your ePortfolio.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

· Competency 1: Develop patient assessments.

. Assess a patient’s condition from a coordinated-care perspective.

. Develop nursing diagnoses that align with patient assessment data.

· Competency 3: Evaluate care coordination plans and outcomes according to performance measures and professional standards.

. Evaluate care coordination outcomes according to measures and standards.

· Competency 4: Develop collaborative interventions that address the needs of diverse populations and varied settings.

. Determine appropriate nursing or collaborative interventions.

. Explain why each intervention is indicated or therapeutic.

· Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.

. Write clearly and concisely, using correct grammar and mechanics.

. Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.