Care Coordination and Discharge Planning Models

COMPETENCIES
7070.18.1 ​ : Incorporating Cultural Awareness
The graduate develops a plan to incorporate cultural awareness in a healthcare setting
7070.18.2 : Applying Treatment Planning Methods
The graduate applies patient-centered treatment planning methods using evidence-based practice (EBP).
7070.18.3 : Applying Intervention Techniques
The graduate applies intervention techniques using evidence-based research in a healthcare setting.
7070.18.4 : Current Care Delivery
The graduate implements care delivery models, based on sociopolitical drivers, with current financial models and regulations in a variety of healthcare settings.
7070.18.5 : Digital Technologies and Patient Care
The graduate proposes way in which digital technologies may be used for compliance, patient care, and data security.
7070.18.6 : Community Relationships
The graduate explains the importance of developing and maintaining community relationships with the strategic partners across the healthcare continuum.
7070.18.7 : Mitigating Risk and Managing Chronic Illness and End-of-Life Care
The graduate creates strategies to mitigate risk and manage chronic illness and end-of-life care in various healthcare settings.
INTRODUCTION
In this course, we have examined models of healthcare in the United States and how emerging trends created by social and political drivers are transitioning these models from fragmented systems with unsustainable costs, suboptimal outcomes, and disparities in care to cohesive systems focused on quality-centered patient systems. A transition to greater coordination of care across providers and settings to improve quality of care and patient outcomes, as well as reduce spending—especially as it attributes to unnecessary emergency room utilization and repeated and unnecessary hospitalizations—is essential. This transformation of care must provide seamless, affordable, and quality care and focus on disparities, disease-type demographics, and chronic health conditions.
Health service coordinators (HSCs) are positioned to contribute to and lead the transformative changes that are occurring in healthcare by being a fully contributing member of the interprofessional team. These shifts require a new or enhanced set of knowledge, skills, and attributes that center around wellness and population care across the continuum.
The ability to engage in evidence-based practices (EBPs) in the application of patient-centered treatment planning methods is imperative.  The HSC must be able to identify appropriate EBPs, as well as choose and appropriately implement methods based upon specific patient needs, all while maintaining a focus on the provision of quality, patient-centered care across the continuum of healthcare and throughout the disease process.  A significant role of the HSC is discharge planning. Connecting patients with appropriate resources—both internally across disciplines and externally across the healthcare continuum—is essential to make the transition to improved quality of care and patient outcomes while reducing cost. Developing and maintaining relationships with community stakeholders to secure patient compliance and optimal patient outcomes is also an important aspect of the HSC’s role.
For this task, you are required to outline the components of a discharge plan for a patient that has been admitted to the hospital with complications of congestive heart failure. The patient is expected to be discharged back home. The discharge plans must be based on evidence-based practice, be multi-disciplinary, and depict a continuum of care.
SCENARIO
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.
REQUIREMENTS
Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. The originality report that is provided when you submit your task can be used as a guide.
You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.
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.