NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Name

Capella university

NURS-FPX 6612 Health Care Models Used in Care Coordination

Prof. Name

Date

Patient Discharge Care Planning

Health Information Technology (HIT) plays a critical role in modern healthcare, offering hardware and software systems that manage and safeguard patient data. This digital framework encompasses electronic health records (EHRs), health information exchanges (HIEs), telehealth services, and other digital resources that contribute to efficient healthcare delivery. These tools are essential for improving clinical accuracy, streamlining workflows, and supporting interprofessional collaboration (Sheikh et al., 2021).

In the case of Marta Rodriguez, a freshman university student navigating a complex recovery, integrating HIT into her care plan ensures her clinical information remains organized, comprehensive, and reflective of her health behaviors and social context. Digital systems provide real-time, personalized care opportunities, enhancing clinical decision-making and ensuring that Marta benefits from seamless, continuous care throughout her recovery process.

HIT is especially valuable in transitional care planning, where maintaining communication between care teams is crucial. As Marta shifts from inpatient recovery to home-based care, digital platforms like EHRs and secure communication systems promote alignment among providers. Centralized data access fosters proactive care management, reduces preventable hospital readmissions, and enriches Marta’s overall healthcare experience by addressing her unique medical and cultural needs.

Scenario

Marta Rodriguez faced significant medical challenges after sustaining serious injuries and a systemic infection requiring multiple surgeries and an extended hospital stay. As a Spanish-speaking individual new to Nevada and reliant on student health insurance, Marta’s care requires careful, culturally sensitive planning. It’s vital to ensure her discharge and recovery are coordinated and supportive of her unique situation.

As the lead care coordinator, my responsibility is to manage her transition from hospital to home while ensuring effective interdisciplinary communication. Utilizing HIT tools, team members can access updated patient records, track progress, and collaborate in real time. This ensures that Marta’s medical, logistical, and cultural needs are addressed cohesively.

Informatics tools enhance this process by enabling digital delivery of educational materials in Marta’s preferred language, online scheduling of follow-up care, and monitoring of medication adherence through telehealth applications. These interventions not only lower healthcare costs but also improve the safety, accessibility, and quality of care Marta receives, supporting her recovery and overall well-being.

Longitudinal Patient Care Plan

Designing a longitudinal care plan for Marta requires integrating centralized EHRs and care coordination platforms. EHR systems consolidate her health history, medication records, surgical interventions, and personal preferences, facilitating evidence-based, informed care decisions. This centralized information ensures continuity and supports the goals outlined in the Triple Aim framework: improving patient experience, enhancing population health, and reducing healthcare costs (Reza et al., 2020).

Additional platforms such as CareTeam and CareMessage can assist in streamlining team communication, managing appointments, and monitoring Marta’s recovery milestones. These systems enable timely adjustments to care plans based on real-time data, improving the delivery of personalized, responsive care (de Witt et al., 2020).

Moreover, integrating advanced technology solutions like remote patient monitoring devices and telehealth platforms ensures Marta receives consistent follow-up care without frequent hospital visits. These tools aid in tracking vital signs and supporting virtual consultations, promoting early detection of complications and reducing barriers to care access (Coffey et al., 2022).

Table 1

Technologies Supporting Marta’s Longitudinal Care

Technology	Purpose	Impact on Care
Electronic Health Records	Centralize Marta’s medical history	Improve continuity and informed clinical decision-making
Remote Patient Monitoring	Track vital signs and health data post-discharge	Enable proactive interventions and prevent hospital readmissions
Telemedicine Platforms	Provide virtual consultations	Increase healthcare accessibility and consistent follow-ups
Patient Portals (e.g., MyChart)	Allow Marta to view health records and communicate with providers	Empower self-management and patient engagement
Clinical Decision Support Systems	Offer evidence-based treatment recommendations	Enhance the safety, efficiency, and personalization of care

Data Reporting Pertinent to Client Behaviors

HIT-driven data reporting is a transformative aspect of care coordination, enabling providers to monitor patient-specific behaviors and intervene promptly when necessary. By identifying patterns such as missed medication doses or skipped appointments, healthcare teams can address these issues through personalized interventions like medication reminders or telehealth counseling sessions (Ogundipe, 2024).

This form of data reporting also facilitates continuous care improvement. When health outcomes or behavior trends indicate a need for adjustment, care plans can be revised proactively. This data-informed approach ensures timely, evidence-based clinical decisions that respond to Marta’s evolving needs (World Health Organization, 2021).

Further benefits include improved clinical efficiency. By analyzing trends such as frequent emergency visits or inconsistent follow-ups, healthcare providers can implement preventive strategies and reduce unnecessary resource utilization. Data-sharing across the interdisciplinary team fosters innovation and ensures Marta receives adaptable, patient-centered care (McLaney et al., 2022).

Table 2

Evaluation Criteria for Data Quality in Marta’s Care

Criterion	Definition	Importance in Marta’s Care
Accuracy	Data reflects Marta’s actual behaviors	Supports precise diagnoses and appropriate interventions
Completeness	Inclusion of all relevant health data	Enables comprehensive care planning
Reliability	Consistency and dependability over time	Builds confidence in health trends and long-term care decisions
Relevance	Data is clinically useful and actionable	Personalizes care decisions and reduces unnecessary interventions

Using Client Records to Positively Influence Health Outcomes

Structured and consistent use of patient records within HIT systems enhances healthcare outcomes by ensuring real-time, data-driven care. Marta’s records provide a comprehensive view of her medical journey, from initial trauma to ongoing recovery, supporting personalized and context-aware care planning (Aminabee, 2024). By making this information accessible to all care providers, care inconsistencies are minimized, promoting seamless communication across settings.

Effective record management is essential for facilitating smooth transitions between providers. When Marta consults new specialists, EHR access to her treatment history prevents redundancy and minimizes risks such as medication interactions. This results in more accurate, coordinated, and effective care (Vos et al., 2020).

Additionally, analyzing Marta’s clinical data—covering health indicators like mobility status, glucose levels, and medication adherence—supports evidence-based adjustments to her care plan. These insights guide decisions about medications, therapy regimens, or lifestyle interventions, ensuring her care is continually refined to optimize outcomes (Ruaya, 2023).

Assumptions

The implementation of HIT within Marta’s care plan operates on the assumption that these systems enhance care coordination, enable personalized care, and improve overall patient outcomes. Real-time documentation and record-sharing promote teamwork and timely interventions, reducing errors and redundancies (Okolo et al., 2024).

Secure messaging features also facilitate quick, confidential communication between care providers, enabling prompt discussions and collaborative decision-making. These functionalities not only improve care delivery but also create a supportive, patient-centered clinical environment (Machon et al., 2020).

Conclusion

The incorporation of Health Information Technology into Marta Rodriguez’s discharge planning and longitudinal care strategy ensures comprehensive, accurate, and actionable healthcare management. These systems promote seamless communication, real-time collaboration, and personalized care decisions tailored to Marta’s evolving needs. Through tools such as EHRs, telehealth services, and data-driven care adjustments, HIT minimizes hospital readmissions, enhances patient engagement, and ultimately improves health outcomes.

References

Aminabee, S. (2024). The future of healthcare and patient-centric care: Digital innovations, trends, and predictions. IGI Global. https://www.igi-global.com/chapter

Avdagovska, M., Ballermann, M., Olson, K., & Nitsch, K. (2020). The use of MyChart by patients with multiple chronic conditions: Qualitative study. JMIR Medical Informatics, 8(12), e21598. https://doi.org/10.2196/21598

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Coffey, J. D., et al. (2022). Telehealth and remote monitoring in post-discharge care: Reducing readmission risks. Journal of Telemedicine and Telecare, 28(1), 25–34.

de Witt, J., McConnell, H., & Fabian, A. (2020). Interprofessional care coordination using digital health platforms. Healthcare Technology Letters, 7(2), 40–48.

Machon, C., Henderson, J., & Lopez, A. (2020). Secure communication in clinical coordination: Best practices. Nursing Management, 51(7), 24–30.

McLaney, E., Chavez, L., & O’Donnell, K. (2022). Innovation in interprofessional teams through data sharing. Health Systems Management Journal, 36(4), 310–317.

Ogundipe, O. (2024). Behavioral data and coordinated care: Trends and tools. Global Journal of Health Informatics, 12(1), 45–52.

Okolo, T., Zhang, Q., & Ferris, M. (2024). Real-time EHR collaboration: Enhancing care transitions. Medical Informatics Quarterly, 18(3), 172–181.

Reza, S. M., Johnson, J. L., & Bailey, T. (2020). EHR and Triple Aim integration in patient-centered care. Health Services Research, 55(S2), 180–193.

Ruaya, S. (2023). Data-driven care planning for chronic conditions. Clinical Informatics Review, 14(1), 89–98.

Sheikh, A., Sood, H. S., & Bates, D. W. (2021). Leveraging HIT to improve quality and safety. BMJ Quality & Safety, 30(5), 387–390.

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

Vos, J., Borgert, M., & Hartmann, R. (2020). Clinical information continuity and patient outcomes: A systematic review. Journal of Medical Systems, 44(7), 119.