NURS FPX 6612 Assessment 3

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NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

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In response to the Institute of Medicine’s (IOM) seminal report, “To Err Is Human: Reducing Health Care Disparities: An Imperative to Act,” hospitals and other healthcare institutions have been advised to adopt Health Information Technology (HIT) as a means to improve patient safety and quality of patient care. This shift of emphasis further highlights the importance of using HIT in the discharge care planning: such as the elimination of gaps in the process and reduction of adverse events after discharge. One of the most critical roles in Marta’s case is that of a senior care coordinator responsible for her transition from the hospital to a home environment. In this regard, it is vital to discuss how the HIT technology can be used to facilitate the development of a comprehensive and patient-centered discharge care plan. The following paper investigates the efficiency of HIT elements, data reporting and Electron Health Record (EHR) data for the better coordination of Marta’s care and potential improvement of the outcomes. Such an analysis of the key considerations can educate the interdisciplinary team on MARTA’s communication strategies about the discharge of the patient, with an emphasis on how IT plays a significant impact on proper discharge planning and patient safety.

Longitudinal, Patient-Centered Care Plan

Health Information Technology (HIT) is a key element of integrated process for the delivery of a patient-centered care plan that provides providers with a longitudinal view of an individual’s care across the continuum of care. It is possible to integrate HIT into the care planning process in order to provide continuity of care, engagement of patients in the processes of care, and to support planning the individualized treatment depending on the patient’s needs (Hersh, 2019). As a form of HIT, EHRs are also of significant impact to the longitudinal care planning. EHRs which are essentially electronic databases in the form of patient files contain medical history information as well as diagnostic tests, medications and treatment plans (HIMSS 2020). By collecting these data and putting all of them into one place, healthcare providers can know how Marta’s condition is progressing and plan future interventions accordingly. This longitudinal view allows providers to adjust their interventions to Marta’s changing health status and desires throughout the healthcare process is then often referred to as more continuous and consistent.

HIT helps to ensure patient-centred care by increasing greater involvement of the patient in the care process, as in the case of the patient we are talking about – Marta. The patient portals and mobile health applications provide access to health information and support the communication between the patients and the care team as well as the learning opportunities for self-management (Zhou et al., 2021). Through these platforms, the patient can see her treatment plan, see her progress, or even give feedback to her providers). This enables Marta to have a sense of ownership of her care regime and also helps clinicians to stick to the care plan of the individual in accordance with their values, goals and culture.

Ways in Which Data Reporting Specific to Client Behaviors Can Shape Care Coordination

Client-focused data reporting can contribute to different components of care, like care coordination, management, efficiency of care in clinical work of health workers and also innovation development between professionals. Using KPIs and other metrics and understanding trends in client behavior allows healthcare providers to better target interventions and allocate staffing and funding appropriately (as well as identify opportunities for improvement in care). The ways data reporting can affect on care coordination are as follows: a) It can highlight the existing gaps or inefficiencies of the care process. For example, reporting on patient data can measure adherence to medication schedules to identify such patients in need of extra educational and motivational or informational support. In the same way, keeping track of appointment attendance and follow up care can enable the healthcare professionals to approach those patients that stop engaging with the healthcare systems and educate them about available care alternatives (Sullivan et al. , 2020). For instance, in the case of care management, the use of data can help in preparing interventions for treatment and care planning depending on the behaviors developed by clients. For example, using statistics to identify changes in a patient’s vital signs, the seriousness of the symptoms, and the patient’s self-assessment can help determine how to modify the drugs being administered or the type of treatment or lifestyle suggestions. Furthermore, by incorporating data from wearable devices or telemedicine connected devices healthcare organizations are able to get client data on their actions outside of the hospital and thus provide them with better tailored and proactive approach.

Information Collected from Client Records

Engaging in HIT enables the use of client information in the system to have a positive impact on health outcomes via several channels. Through data mining existing datasets from EHRs, clinical notes, lab results, and PROMs, healthcare providers can gain actionable knowledge about patients’ health, treatment choices, or outcomes. This information also forms the basis on which evidence-based decisions are made, the creation of care plans that are customized to patients and patient populations, and the implementation of intervention strategies in a proactive manner to attain health outcomes (Ahmadian et al. , 2019). The inclusion of such information for health outcomes may involve the early discovery of health conditions through the client records. It will also help in evaluating the risk factors, disease conditions and state of health that is deteriorating through data analysis. For instance, abnormal laboratory findings, changes in vital signs, or variations of the treatments prescribed in the client’s chart can be considered leading indicators of emerging difficulties or the necessity to switch the focus of care. It becomes evident that failing to act quickly is not appropriate and may lead to the exacerbation of health conditions or the occurrence of adverse events and a negative impact on the treatment process.


According to the discussion, it is clear that effective patient discharge care relies on the ability to use Health Information Technology or HIT to coordinate transitions, deliver personalized care, and meet the care goals and objectives. The concept of HIT enables healthcare practitioners to establish cohesive care plans through EHRs, patient portals, and predictive modeling software to integrate care that meets patients’ needs around individual preferences and circumstances. The inter-professional team may easily work with the help of HIT to decrease the number of adverse events after discharge as well as to coordinate various stages of treatment better. Equally important is the data which directly focuses on client data behavior to determine health status, treatment response, and preference in care. Client drivers could be helpful to healthcare providers to help in the development of strategic interventions that can improve the healthcare delivery system in various ways from identifying necessary changes in client behaviors to devising client-specific approaches to achieve quality improvements in healthcare.

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Ådnanes, M., Cresswell-Smith, J., Melby, L., Westerlund, H., Šprah, L., Sfetcu, R., Straßmayr, C., & Donisi, V. (2019). Discharge planning, self-management, and community support: Strategies to avoid psychiatric rehospitalisation from a service user perspective. Patient Education and Counseling, 103(5).

Considine, J., Berry, D., Sprogis, S. K., Newnham, E., Fox, K., Darzins, P., Rawson, H., & Street, M. (2020). Understanding the patient experience of early unplanned hospital readmission following acute care discharge: A qualitative descriptive study. BMJ Open, 10(5), e034728.

Emes, M., Smith, S., Ward, S., & Smith, A. (2019). Improving the patient discharge process: Implementing actions derived from a soft systems methodology study. Health Systems, 8(2), 117–133.

Haselden, M., Corbeil, T., Tang, F., Olfson, M., Dixon, L. B., Essock, S. M., Wall, M. M., Radigan, M., Frimpong, E., Wang, R., Lamberti, S., Schneider, M., & Smith, T. E. (2019). Family involvement in psychiatric hospitalizations: Associations with discharge planning and prompt follow-up care. Psychiatric Services, 70(10), 860–866.

Hayajneh, A. A., Hweidi, I. M., & Abu Dieh, M. W. (2020). Nurses’ knowledge, perception and practice toward discharge planning in acute care settings: A systematic review. Nursing Open, 7(5), 1313–1320.

Loerinc, L. B., Scheel, A. M., Evans, S. T., Shabto, J. M., O’Keefe, G. A., & O’Keefe, J. B. (2021). Discharge characteristics and care transitions of hospitalized patients with COVID-19. Healthcare, 9(1), 100512.

Luther, B., Wilson, R. D., Kranz, C., & Krahulec, M. (2019). Discharge processes: What evidence tells us is most effective. Orthopaedic Nursing, 38(5), 328–333.

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