Comprehensive Needs Assessment Essay.

A comprehensive health needs assessment enables providers to understand the health requirements of individual patients. Consequently, healthcare practitioners use available resources, knowledge, and competence systematicallyto disperse care efficiently to all patients. Provided care improves the overall level of patient satisfaction and experience. This paper will focus on the comprehensive needs assessment of a sample patient, Mr. Decker. Additionally, it will discuss the assessments’ role in identifying and addressing gaps in the provided patient care through care coordination. Strategies for gathering additional data will also be addressed.Comprehensive Needs Assessment Essay.

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Patient Assessments

Current Gaps in a Patient’s Care

The client, a 79-year-old man, Mr. Fred Decker, had visited at St. Anthony Medical Center two weeks ago. The client had a badly infected toe. The infection cleared up after treatment, and he was discharged with some instructions. However, the client and his family failed to adhere to the provided instructions. Consequently, the infection worsened, making the client return to the hospital three days later for assessment and treatment where he was diagnosed with sepsis. The following gaps were responsible for his readmission.Comprehensive Needs Assessment Essay.

• Failure to educate the patient on how to utilize the provided instructions while at home: The client could not manage his condition at home after being discharged due to a lack of understanding of the provided guidelines.
• Failure to utilize an interdisciplinary approach to care: Healthcare providers failed to ensure that some factorssuch asdiabetes and aging were considered during care provision.
• Failure to collaborate with other professionals during care delivery: The primary care provider failed to engage other specialistsduring care delivery.
• Failure to consider the patient’s support system before discharging him: The healthcare provider failed to consider if the patient had the required support system to facilitate his recovery while at home.
• Failure to consider the client’s financial status: The healthcare providers failed to consider the patient’s low economic status while designing his treatment plan.Comprehensive Needs Assessment Essay.

Strategy for Gathering Additional Data

Additional data would be required to enhance the management of the client’s current condition. First, the required details will be acquired from the client’s electronic health record systems (EHRs). EHRs are patient-centered records that instantly avail the patient’s information to authorized users(Schopf et al., 2019). Therefore, the healthcare provider will understand the client’s medical history, including surgeries and any medication administered in the past. This information will guide the practitioner in providing evidence-based care to the patient. Furthermore, the practitioner will gather more data by interviewing the client’s close relatives. His family members, including his wifeand siblings, will provide details of his medical history. This information will guide the practitioners in developing the most suitable treatment plan for the client.Comprehensive Needs Assessment Essay.

The Impact of Societal, Economic, and Interprofessional Factors on Patient Outcomes

Societal Factors

Societal factors

These factors had an adverse effect on the patient’s outcomes. First, his outcomes wereaffected by dietary choices. Aged individuals are supposed to consume a balanced diet with limited carbohydrates and a high amount of proteins and vitamins. A nutritious diet facilitates the healing of wounds, especially among elderly patients. Therefore, the lack of a balanced diet compromised Mr. Decker’s healing. Additionally, his outcomes were affected bysocial support. Specifically, his age requires social support to facilitate healing. According to Iglesias and Arias(2015), structural and functional social supportresults in functional and subjective improvements in patient satisfaction and outcomes.However, Mr. Decker has limited social support. He lives with his aged wife and a granddaughter. The wife cannot accord the necessary support due to her age, while her granddaughter has a tight schedule at work and school. Therefore, it is relatively challenging for her to accord Mr. Decker the required social support. Lack of support made it difficult for the client to adhere to care instructions given by the providers, which, in turn, compromised patient outcomes.Comprehensive Needs Assessment Essay.

Economic factors

The client’s financial status had a significant impact on the outcomes. Mr. Deckerrequiredmoney to purchase the prescribed medication and a balanced diet. Additionally, the client required funds to finance a medical cover despite being entitled to on Medicare program. Therefore, patient outcomes depend on his financial status.Comprehensive Needs Assessment Essay.

Interprofessional Factors

The outcomes might be affected by interprofessional factors. Institutional support, such as the medical facility’s leadership and governance are likely to affect the outcomes through the quality of care. Additionally, working culture support, such as the use of effective communication strategies, will have an impact on the outcomes. Quality of care will be improved if effective communication is utilized during the provision of care. Finally, the level of outcomes will significantly depend on professional support. For instance, the quality of care will be improved if practitioners have a common interest. Thus, interprofessional factors have an impact on the outcomes.Comprehensive Needs Assessment Essay.

The Relationship between the Patient and Care Coordination OutcomesMeasures and Professional Standards

The set standards of care can be used to measure patient outcomes and safety and care coordination. Patient and care coordination outcomes for the client are satisfactory if they align with the set standards. National Quality Forum’s safety report is used as the basis for measuring the safety outcomes of patient care. This report will be effective since it primarily focuses on the development of safety measures.Additionally, the Care Coordination and Transition Management Logic Model will measure the quality outcomes of care coordination. This model will be effective since it links nurse competencies, care coordination, and outcomes. Therefore, the model will indicate how nurse competencies and care coordination will result in improved patient outcomes.Comprehensive Needs Assessment Essay.

Evidence-Based Practices for Successful Implementation of Care Coordination

Various evidence-based practices have been effective in the implementation of successful care coordination for patients withsepsis. First, a multi-and interprofessional team has been effective in the management of sepsis. Providers within the primary care setting are trained on how to manage sepsis. Secondly, the team care approach for patients with sepsis has been effective and safe in managing sepsis.Comprehensive Needs Assessment Essay. The team care approach involves educating individuals about the condition and associated health complications. Therefore, this approach helpsindividuals to cope with various complications associated with sepsis. Finally, GENeralized Early Sepsis Intervention Strategies (GENESIS) is effective in the management of sepsis. This initiative was introduced to facilitate the continuous improvement of individuals diagnosed with sepsis(Armen et al., 2016). Specifically, this program contains pertinent treatment measures, which guide patients and their families, thus enabling them to manage sepsis.Comprehensive Needs Assessment Essay.

Implementation of Care Coordination

The implemented care for Mr. Decker should be based a plan of care from a population-health perspective. The population perspective approach states that health outcomes are influenced by three major factors, including social, psychological, and environmental factors. In other words, casual agents, among other factors, are responsible for health outcomes. Therefore, some practices and guidelines should be implemented to improve health outcomes. The Surviving Sepsis Campaign guidelines should be used during care delivery. These guidelines have been effective in the treatment of elderly patients with sepsis (Rhodes et al., 2017). Thus, utilizing this approach during the treatment of Mr. Decker will improve patient outcomes significantly.Comprehensive Needs Assessment Essay.

The Benefits of a Multidisciplinary Approach to Patient Care

A multidisciplinary approach to patient care will accrue a wide range of benefits to the patient and the healthcare providers. It involves an integrated team approach to healthcare(Mao& Woolley,2016). This approach’s key benefit to the patient includes enhanced client satisfaction and improved patient outcome due to high-quality care. On the other hand, healthcare providers will benefit from the efficient use of resources since minimum resources will be used during care delivery. Additionally, the team members will benefit from enhanced job satisfaction. The satisfaction will occur due to improved quality of care that leads to enhanced patient outcomes.Comprehensive Needs Assessment Essay.

Conclusion

A comprehensive needs assessment of patient care has enhanced patient outcomes and satisfaction of Mr. Decker. Various factors, including societal, economic, and interpersonal, are likely to impact patient outcomes. Patient outcome and coordinate care are measured based on the set standards. The National Quality Forum’s safety report is used to measure the safety outcomes of patient care. Additionally, the Care Coordination and Transition Management Logic Model is used to measure care coordination’s quality outcomes. Various evidence-based approaches can beutilized to improve the quality of care provided to the client. Finally, the implementation of care coordination will improve the health outcomes of this patient.Comprehensive Needs Assessment Essay.

Congratulations! You have been just hired as a case management intern in the Care Coordination Department at St. Anthony Medical Center. Located in Minneapolis, St. Anthony is a 120-bed hospital in the Vila Health system, which operates facilities in several Midwest states. The Care Coordination Department manages patient cases throughout the entire hospital.Comprehensive Needs Assessment Essay.

Since it’s your first day, your first task is to get oriented. Your preceptor will help you get started. To learn more about the roles that care coordinators play in nursing, you’ll be talking with experienced case managers, social workers, and other members of the team. You’ll also sit in on a coordination planning meeting.Comprehensive Needs Assessment Essay.

Email

Your first day, 1^st New email

From: Denise McGladrey, Preceptor

To: The New Hire

Welcome to St. Anthony! We’re so glad to have you on the Care Coordination team. As you know, I am going to be your preceptor. My job is to help you transition into your new role as case management intern and to offer you support. You should feel free to come to me with questions.Comprehensive Needs Assessment Essay.

2^nd New Email

Patient meeting

From: Denise McGladrey, Preceptor

To: The New Hire

I see you’ve been busy meeting with team members to learn more about care coordination roles and trends. Thank you so much for doing that!

I have another task for you that will help you get oriented. There’s going to be a meeting this afternoon to discuss care coordination strategies for a patient. Here’s the background: a 79-year-old man named Fred Decker was seen here two weeks ago with a badly infected toe. After the infection cleared up, he was sent home with instructions. Unfortunately, he and his family weren’t able to follow the instructions, and he returned to the hospital three days later with an infection that was even worse—and now he has sepsis. As you know, that’s a serious red flag. Care coordinators need to be seriously concerned with readmission rates, as these reflect poorly on the hospital and impact our ability to be reimbursed by Medicare.Comprehensive Needs Assessment Essay.

Mr. Decker is responding well to antibiotics, thankfully. This afternoon, several members of the team are having a meeting to discuss his care.

Here’s what I want you to do. Go to the meeting, and just listen. At future meetings throughout your internship, you’ll offer your feedback, but for today, I just want you to be a “fly on the wall.” Afterwards, you’ll meet with me. I’ll ask you some questions about the meeting and provide you with some feedback.Comprehensive Needs Assessment Essay.

Thanks for all your hard work!
Denise

TEAM MEETING: Between.

Samantha Rockwell (social worker), LucasBranch (diabetes educator),

Vicki Vasquez (director of case management) and SethPatterson (case management)

It looks like you’ll be listening in on a meeting.Comprehensive Needs Assessment Essay.

Let’s hear what your new colleagues have to say about this patient.

Vicki: So, Seth, you were the case coordinator who was working with Mr. Decker and his family. Can you tell me what happened?

Seth: Well, as you know, Mr. Decker came in with a badly infected toe. He was diagnosed with diabetes last year. It sounds like he hasn’t been treating it effectively.Comprehensive Needs Assessment Essay.

Vicki: Why do you say that?

Lucas: I spoke with Mr. Decker and his wife. It sounds like he’s been forgetting to take his insulin. He said that’s only happened twice, but I got the sense from his wife that it happens fairly often. Plus they both told me his diet hasn’t changed much since the diagnosis. He’s lost about 10 pounds, which is great. But he’s still in the obese range.Comprehensive Needs Assessment Essay.

Vicki: That’s too bad. Was the diabetes related to the toe infection?

Seth: It was probably a factor. He cut his toe while walking his dog. His wife washed the cut and put a bandage on it. But it got worse. A nephew finally took him to his primary physician, since he and his wife don’t drive on freeways anymore. The physician sent Mr. Decker to the hospital.

Vicki: So explain to me what happened when Mr. Decker came here the first time.

Seth: Mr. Decker was given antibiotics and the infection started to clear up after a two-day stay. Medicare wanted to send him home with antibiotics. We weren’t aware that his toe wound had progressed and he had developed a more resistant infection.Comprehensive Needs Assessment Essay.

Vicki: That’s too bad. Samantha, what was your involvement in this case?

Samantha: I met with Mr. and Mrs. Decker. I was definitely concerned that Mr. Decker wouldn’t take the antibiotics if we sent him home. He also needed to treat the infection site twice a day. Mrs. Decker assured us that us that she would take care of her husband and make sure the infection was treated. But I was leery because it doesn’t sound like the diabetes or the original cut was treated very well.Comprehensive Needs Assessment Essay.

Vicki: So why was he sent home?

Seth: Well, for one thing, we talked to the Deckers’ nephew—the one who drove him to the doctor and the hospital. He said that his wife was a stay-at-home mom and that she could stop by twice a day to take care of Mr. Decker. Apparently this couple lives in the same neighborhood as the Deckers. Also, the Deckers’ daughter was planning to fly in from California later that week to take care of him.Comprehensive Needs Assessment Essay.

Vicki: Did that happen?

Seth: No. Apparently there was a last-minute emergency at the daughter’s workplace, so she wasn’t able to come. And it’s unclear to me how often the nephew and his wife stopped by.

Samantha: Yeah. I spoke with the nephew. Apparently his wife wasn’t happy about being volunteered for this situation. It sounds like she only stopped by a few times.

Vicki: So now Mr. Decker is back. It sounds like he is responding well to the new round of antibiotics.Comprehensive Needs Assessment Essay.

Seth: Thankfully, yes. At first we thought an amputation might be necessary. But he’s doing remarkably well. He might be able to go home next week—except that we know that’s not a realistic option.

Vicki: So what’s next?

Samantha: The Deckersdon’t have the resources to pay for much that Medicare won’t cover. A rehabilitation center might be a good option, but it will be a challenge to find one they can afford. Other options would be home health care or an outpatient infusion center.Comprehensive Needs Assessment Essay.

Vicki: Seth and Samantha, what are your thoughts about the outpatient infusion center?

Seth: At this point, I think that’s the best option. Mr. Decker doesn’t need rehabilitation. He just needs someone to administer the antibiotics.Comprehensive Needs Assessment Essay.

Samantha: I actually think a skilled nursing facility might be the better option. We’ve seen that the Deckers aren’t able to handle this themselves, and that they don’t have a good enough support system to help. The infusion center would only help with the antibiotics. We need to make sure the infection site is cared for and that he gets some help with his diabetes as well.Comprehensive Needs Assessment Essay.

Seth: But that’s an expensive option they may not be able to afford—and I don’t think that level of care is necessary.Comprehensive Needs Assessment Essay.

Samantha: But I just can’t picture sending Mr. Decker home yet. I’m afraid he’ll wind up back here again—or worse.

Requirements

Complete a comprehensive needs assessment for a 79-year-old man named Fred Decker who was seen here at St. Anthony Medical Centertwo weeks ago with a badly infected toe. After the infection cleared up, he was sent home with instructions. Unfortunately, he and his family weren’t able to follow the instructions, and he returned to the hospital three days later with an infection that was even worse—and now he has sepsis,based on the information provided in the Vila Health simulation above and your own research.Comprehensive Needs Assessment Essay.

Comprehensive Needs Assessment Format and Length

Format your comprehensive needs assessment using APA style:

• Use the APA Style Paper Template [DOCX] provided. Be sure to include:

• Your needs assessment should be 4–5 pages in length, not includingthe title page and references page.

Supporting Evidence

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

Conducting the Assessment

The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your needs assessment addresses each point, at a minimum. Read the Comprehensive Needs Assessment Scoring Guide to better understand how each criterion will be assessed.Comprehensive Needs Assessment Essay.

• Identify current gaps in a patient’s care.

• Use an appropriate needs assessment tool to identify gaps. This tool may be one in use at your place of employment, one you locate for yourself, or one provided by faculty.
• Consider the types of patient information that will be most useful in assessing the current level of care.Comprehensive Needs Assessment Essay.

• Develop a strategy for gathering additional necessary assessment data not readily available from an initial patient interview.
  • Consider the full range of interrelated needs that affect the patient’s health.
• Discuss 3–5 societal, economic, and interprofessional factors most likely to affect patient outcomes.
  • Consider the potential effects of these factors on outcomes.
  • Support your conclusions with evidence.
• Relate specific patient and care coordination outcome measures to professional standards.Comprehensive Needs Assessment Essay.
  • Provide the rationale for measuring outcomes based on established agencies and organizations.
  • Describe the relationship between specific outcomes and the identified standards.
• Identify evidence-based practices for successful implementation of care coordination.
  • Use relevant and credible sources from the research literature.
  • Consider best practices for a population-health focus on patient outcomes.
• Advocate for the benefits of a multidisciplinary approach to patient care.
  • Provide the key points in your argument.
  • Support your assertions with evidence.
• 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 more difficult to focus on the substance of your needs assessment.
• Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.Comprehensive Needs Assessment Essay.

Comprehensive Needs Assessment

A comprehensive health needs assessment enables providers to understand the health requirements of individual patients. Consequently, healthcare practitioners use available resources, knowledge, and competence systematicallyto disperse care efficiently to all patients. Provided care improves the overall level of patient satisfaction and experience. This paper will focus on a comprehensive needs assessment of a sample patient, Client X. Additionally, it will discuss the assessments’ role in identifying and addressing gaps existing in the provided patient care through care coordination. Strategies for gathering additional data will also be discussed.

Competency 1: Patient Assessments

Current Gaps in a Patient’s Care

Client X, a 35 years-old African American, was admitted to the healthcare facility with brittle diabetes. The condition was managed, and the client was discharged after seven days with someself-managementtips that would enable him to manage the condition while at home. Three weeks later, the client was returned to the hospital due to the deterioration of his condition. His situation was worse than during the first admission. The following gaps were responsible for his readmission.Comprehensive Needs Assessment Essay.

• Failure to educate the patient on how to utilize the diabetes self-management tool while at home: The client could not manage his condition at home after being discharged due to a lack of understanding of the self-management tool.
• Failure to utilize an interdisciplinary approach to care: Healthcare providers could not ensure that some factors that trigger diabetes, such as obesity and high blood pressure, were considered.
• Failure to collaborate with other professionals during care delivery: The primary care provider failed to engage other specialists, such as nutritionists, during care delivery.
• Failure to consider the patient’s lifestyle before discharging him: The healthcare provider failed to consider the patient’s daily activities such as physical exercise and diet.Comprehensive Needs Assessment Essay.

Strategy for Gathering Additional Data

Additional data would be required to enhance the management of the client’s current condition. First, the required details will be acquired from the client’s electronic health record systems (EHRs). EHRs are patient-centered records that instantly avail the patient’s information to authorized users(Schopf et al., 2019). Therefore, the healthcare provider will understand the client’s medical history, including surgeries and any medication administered in the past. This information will guide the practitioner in providing evidence-based care to the patient. The practitioner will gather more data by interviewing the client’s close relatives. His family members, including his wife, parents, and siblings, will provide details of his medical history. This information will guide the practitioners during care delivery.Comprehensive Needs Assessment Essay.

Competency 2

The Impact of Societal, Economic, and Interprofessional Factors on Patient Outcomes

Societal Factors

Societal factors

These factors will have an adverse effect on the patient’s outcomes. First, his outcomes will be affected by dietary choices. Diabetic individuals are supposed to consume a balanced diet with limited carbohydrates and a high amount of proteins and vitamins. Additionally, his outcomes will be affected by exercise. Diabetic individuals are advised to exercise regularly to manage their body weight and blood sugar levels(Colberg et al., 2016). Therefore, dietary choices and exercises will determine how the patient will respond to the prescribed medication.

Economic factors

Various economic factors will influencethe patient’s outcomes. The client’s income will affect the outcomes significantly. Client X will require financial resources to buy the prescribed medication and a balanced diet. Therefore, effective management of his condition will mainly depend on his level of income. Additionally, the outcomes will be affected by legal measures enacted to guide the treatment of diabetic individuals at the state and national levels. Comprehensive Needs Assessment Essay.

Interprofessional Factors

The outcomes will also depend on interprofessional factors. Institutional support, such as the medical facility’s leadership and governance, will affect outcomes through the quality of care. Additionally, working culture support, such as the use of effective communication strategies, will have an impact on the outcomes. Quality of care will be improved if effective communication is utilized during the provision of care. Finally, the level of outcomes will significantly depend on professional support. For instance, the quality of care will be improved if practitioners have a common interest.Comprehensive Needs Assessment Essay.

The Benefits of a Multidisciplinary Approach to Patient Care

A multidisciplinary approach to patient care will accrue a wide range of benefits to the patient and the healthcare providers. It involves an integrated team approach to healthcare(Mao& Woolley,2016).This approach’s key benefit to the patient includes enhanced client satisfaction and improved patient outcome due to high-quality care. On the other hand, healthcare providers will benefit from the efficient use of resources since minimum resources will be used during care delivery. Additionally, the team members will benefit from enhanced job satisfaction.The satisfaction will occur due to improved quality of care that leads to enhanced patient outcomes.Comprehensive Needs Assessment Essay.

Competency 3: The Relationship between the Patient and Care Coordination OutcomesMeasures and Professional Standards

The set standards of care can be used to measure patient outcomes and safety and care coordination. Patient and care coordination outcomes for Client X are satisfactory if they align with the set standards. National Quality Forum’s safety report is used as the basis for measuring the safety outcomes of patient care. This report will be effective since it primarily focuses on the development of safety measures.Additionally, the Care Coordination and Transition Management Logic Model will measure the quality outcomes of care coordination. This model will be effective since it links nurse competencies, care coordination, and outcomes. Therefore, the model will indicate how nurse competencies and care coordination will result in improved patient outcomes.Comprehensive Needs Assessment Essay.

Competency 4: Evidence-Based Practices for Successful Implementation of Care Coordination

Various evidence-based practices have been effective in the implementation of successful care coordination for patients with severe diabetes. First, a multi-and interprofessional team has been effective in the management of diabetes. Providers within the primary care setting are trained in diabetes management measures. The team members work collaboratively with the primary care provider during care delivery. Diabetes specialists, in turn, support primary care providers either directly or indirectly through shared care(Clement et al., 2013). This care model has improved A1C and blood pressure (BP) among adults with T2D significantly.Secondly, the team care approach for diabetesmanagement has been effective and safe in regulating diabetes. The team care approach involves educating individuals about various complications of diabetes.Comprehensive Needs Assessment Essay. Therefore, the approach helps diabetic individuals to cope with various complications associated with the condition. Specifically, the approach lowers the possibility of microvascular complications such as kidney disease and eye disease. Additionally, it minimizes chances of macrovascular complications such as stroke and heart disease, among other complications. Furthermore, effective behavioral interventions reduce the risk ofdiabetes. Additionally, they facilitate glycemic control, thus delaying the condition’s progression to further complications such as kidney failure, nerve damage, loss of vision, cardiovascular disease, and the amputation of the lowerextremity. The effective management of diabetic symptoms, in turn, improves the level of patient outcomes and satisfaction.Comprehensive Needs Assessment Essay.

Competency 5: Effective Communication

Effective communication will play a vital role in delivering the intended message to various audiences. The form andthe style of communication mainly depend on the targeted audience and the set standards. First, the communication strategy should meet organizational standards. Most organizations prefer formal communication to deliver a message to various team members. A hierarchical structure and chain of command are utilized during communication. The top managers release information to their assistants, who ensure that the message is disseminated to all organization members. Professional standards are also considered during communication. Healthcare practitionersare expected to adhere to professional measures while communicating with each other during care delivery.Comprehensive Needs Assessment Essay.

Conclusion

A comprehensive needs assessment of patient care has enhanced patient outcomes and satisfaction of Client X. Various factors, including societal, economic, and interpersonal, impact patient outcomes. Patient outcome and coordinate care are measured based on the set standards. The National Quality Forum’s safety report is used to measure the safety outcomes of patient care. Additionally, the Care Coordination and Transition Management Logic Model is used to measure care coordination’s quality outcomes. Various evidence-based approaches can beutilized to improve the quality of care provided to the client. These approaches include a multi-and interprofessional team, a team care approach, and effective behavioral interventions. Finally, effective communication strategies enhance the delivery of the message to the targeted audiences. Healthcare practitioners are expected to adhere to organizational and professional standards while communicating with other team members.Comprehensive Needs Assessment Essay.