Care Coordination and Discharge Plan for Congestive Heart Failure Patient

A 70-year-old male patient has been admitted to the hospital with complications of stage 4 congestive heart failure and is anticipated to be discharged in two days.
The life expectancy of this patient is less than six months. The patient is in denial about his diagnosis and is resistant to discuss additional resources in the home setting. The patient does not currently have a living will. The patient and spouse travelled 100 miles to the hospital; their home community is considered a healthcare professional shortage area. Patient’s support systems include a spouse and two children who live locally. The patient requires oxygen and a walker to ambulate. The patient’s spouse has reported that the patient is anxious about hospital bills and finances moving forward. Both the patient and the patient’s spouse’s primary language is Spanish, and their understanding of the English language is minimal. The patient has been hospitalized for management of congestive heart failure three times in the past 12 months. The patient’s insurance is Medicare.

A.  Research evidence-based practices regarding the patient’s chronic illness to complete the following: 

1.  Provide an annotated bibliography with at least three sources.

2.  Explain how each source from A1 could support a patient-centered discharge plan for this patient.

B.  Based on current models of care delivery, explain which care delivery model would be most beneficial for this patient. 

1.  Summarize a healthcare regulation that influences the discharge plan for this patient. 

2.  Describe ways Medicare funding and current trends in Medicare reimbursement may affect care delivery for this patient.

C.  Identify a digital technology that may be used for regulatory or patient compliance, patient care, or data security.

1.  Explain how the identified digital technology could be integrated into the discharge plan to improve the patient’s outcome.

2.  Discuss ways the identified digital technology could mitigate risk of readmission for the patient. 

D.  Outline the major elements of the patient/family-centered discharge plan by doing the following:

1.  Identify essential strategic partners and organizational stakeholders who should participate in creating the discharge plan.

2.  Identify any individualized interventions needed to meet the patient’s specific needs, based on the patient’s chronic illness.

3.  Discuss the most appropriate engagement technique to motivate the patient’s continuous adherence to the discharge plan. 

4.  Compile a list of resources across the healthcare continuum and explain how the resources will assist this patient in managing the chronic illness and possible end-of-life care 

E.  Discuss two examples of interventions in the discharge plan that are a result of the patient's culture.

1.  Explain how the patient and patient’s family’s understanding of the discharge plan could impact the risk of hospital readmission. 

2.  Discuss how current trends in cultural awareness affect the discharge planning for the patient. 

F.  Reflect on the evolution of healthcare trends and how current delivery models have improved discharge planning and patient outcomes.

1.  Reflect on the importance of developing and maintaining community relationships with the strategic partners across the healthcare continuum. 

G.  Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.

H.  Demonstrate professional communication in the content and presentation of your submission.