Based on the information provided in the case study, it is vital to assess Hannah to pinpoint and understand her needs and support her right to self-determination.
Best Practice Assessment Technique
The bio-psychosocial model is the best practice assessment technique to identify the issues plaguing the patient. This approach involves assessing the biological, psychological, and social determinants or factors affecting the patient’s health and quality of life (Laborde, 2016). It provides an effective opportunity to determine comprehensive needs by employing emotional components and evaluating situations to build predictions. The technique gives the patient the right to self-determination because assessment occurs where there are motivational situations and active participation.
How to Implement the Identified Best Practice Assessment Technique
As a health service coordinator, I would first hold a meeting with Hannah and her family. I would actively engage all stakeholders to help motivate and activate the patient in the care management program (Laborde, 2016). During the implementation process, I would consider the bio-psychosocial aspects of Hannah’s life to ascertain the factors contributing to her problems. I would assess the client’s physical problems, thoughts, psychological health, behavior, and real-life experiences through a bio-psychosocial interview. My team members would further investigate how bio-psychosocial factors affect or compound Hannah’s medical condition. The interdisciplinary team would devise a treatment plan to manage each aspect and address the patient’s needs.
Social Determinants of Health (SDOH) That Attend to Health Needs of the Patient
Social determinants of health (SDOH) denote factors that influence various health risks and outcomes. These determinants include social and community context, environmental conditions and neighborhoods, access to healthcare, and economic status (Centers for Disease Control and Prevention (CDC), 2021). These forces affect people’s health and how to manage patients and meet their day-to-day needs. For instance, positive interactions with families and community members help provide social support, improving a person’s wellbeing and health (CDC, 2021). Hannah gets assistance from a social worker and her family. It is vital to reduce harmful environmental exposures and practice healthy eating to improve the patient’s health and quality of life (Child Welfare League of America (CWLA), 2021). Hannah and her family are low-income individuals, a situation which most likely translates to poor dietary habits. Besides, Hannah does not have a personal house and resides in a condominium in a rural setting with other tenants and under a renewable agreement for a specific period. Climbing two flights of stairs to access the residential condominium proved challenging for a woman supported with oxygen equipment.
Low-income compromises the patient’s ability to access high-quality care and other social services. Even though Hannah has a supportive family, they are unable to hire private aides to assist her. Hannah’s insurance package covered her physical and occupational therapies for five weeks in the in-home care facility. However, the medical insurance could not cover the costs of managing COPD and chronic depression. Furthermore, living in a rural area made her miss palliative appointments due to lack of transport, contributing to COPD exacerbations and extended hospitalizations. Indeed, the SDOH highlighted above strongly influenced Hannah’s physical, behavioral health, and psychological needs. The patient needs social welfare and insurance programs to afford care, attend all appointments, and address economic-related issues.
How to Address Each SDOH through Care Coordination
Care coordination measures can help improve Hannah’s situation by tackling the abovementioned issues. The nurses should serve the patient and her family in a convenient and locally-available healthcare facility. A local hospital builds more opportunities for the patient to interact with her loved ones and community members. Additionally, the comprehensive treatment plan should focus on overcoming the low-income challenge. Hence, the patient must obtain Medicaid insurance cover to afford home-based services, hire personal aides, and pay for hospice care (Fay, 2012). The health cover will also relieve Hannah financially and enable her to afford transportation services, thereby attending all hospital appointments. Such home-visit programs as CAPABLE and social welfare schemes should be a part of the plan to improve Hannah’s safety, wellbeing, and the environment through home repairs (Fulmer et al., 2021, CDC, 2021). Superior housing enhances air quality, reduces exposure to colds and water leaks, and mitigates poor ventilation, preventing health damages (CWLA, 2021). Further, the care coordination plan should incorporate exercises, strong social support networks and relationships, good nutrition, sleep, patient education, and positive coping strategies. These elements will support healthy lifestyle and coping, reducing the patient’s vulnerability to chronic illnesses and mental health problems.
Ethical and Legal Dilemma Related to the Scenario
A major ethical dilemma relates to confidentiality breach. Actualizing the treatment plan requires efforts from different stakeholders, including healthcare professionals and social workers. This process would involve disclosure, thereby compromising information security and privacy. Another dilemma would be divulging the patient’s information to secure financial assistance and support services. In this case, healthcare providers may compromise the privacy of Private Health Information by sharing Hannah’s data with a third party. Due to fear and financial concerns, the patient may refuse treatment to avoid burdening her family. Medical errors may occur during the treatment process, creating legal issues (Kadivar et al., 2017). The hospital personnel should provide the patient and her family with error-related information.
How to Address the Ethical and Legal Dilemmas
Ethical and legal dilemmas should be addressed to meet the patient’s rights and mitigate legal risks. The HSC intern will discuss with the patient about the involvement of other health professionals in the treatment plan implementation to secure her consent in advance. The communication between the HSC and Hannah will assist in obtaining permission for care and service provision. Before the treatment process, the patient and her family have the right to seek information and ask questions about care coordination plans. The healthcare team should inform Hannah and her relatives about any errors committed by the medical professionals (Kadivar et al., 2017). The hospital personnel must use friendly language to explain the situation in question and how they would address it.
Evidence-Based Practice Technique to Help Navigate Through Multiple Healthcare Systems
In the case study, the most suitable evidence-based practice (EBP) technique to assist Hannah in navigating through multiple healthcare systems is the holistic approach. This problem-solving technique integrates data from four major sources, including research evidence, patient values and preferences, information about health care practice context, and clinical skills. The technique would involve identifying the problems contributing to Hannah’s ailments following evidence analysis, data translation into clinical practice, and result evaluations. In other words, this evidence-based practice focuses on treating underlying triggers rather than signs of an illness (Ernst, 2007). The holistic nurses and doctors would deal with the causes of COPD, chronic depression, and osteoarthritis to accommodate Hannah’s needs and improve her health outcomes.
How the Chosen Evidence-Based Practice Benefits the Patient
The technique would help establish the most effective measures to deliver individualized health care to the patient. Holistic practitioners provide a variety of alternative therapies and address the patient’s somatic problems and psychosocial needs (Ernst, 2007). This evidence-based practice is also quite effective in improving health outcomes for the elderly and people with chronic health conditions through whole-person care and support. The healthcare providers must administer effective and safe interventions to maximize the benefits of this approach.
Risks and Benefits of Financial Regulation Outcomes to the Care of Patients
Finance regulation creates challenges and advantages during care delivery. They increase the likelihood of limiting care provision or denying the patient some vital healthcare services, leading to poor health outcomes. The healthcare organization may lose some incentives through penalties for failure to meet quality requirements or value-based care standards (Shrank et al., 2021). Nevertheless, financial regulations build trust with medical insurance institutions covering the patient since they employ strategies that prevent malpractices and improve patterns of healthcare use. Financial policies also help expand insurance coverage, resulting in improved care and equal access to quality and affordable healthcare (Shrank et al., 2021). Hence, they contribute to better patient outcomes by promoting equity and care affordability.
Healthcare Implications of If Federal Compliance Is Not Achieved While Providing Care Coordination
If Healthcare organizations fail to follow healthcare regulations during patient care management, they may incur losses. For example, the inability to achieve federal compliance would increase the risks of security breaches, financial losses, fines and penalties, reputation and trust damage, and license revocations (“Consequences of non-compliance in healthcare,” 2020, Shrank et al., 2021). Medical facilities should meet all standards to maximize value-based reimbursement.
Financial Resource to Help the Patient Maneuver Through the Healthcare System
The best financial resource to help Hannah would be the Medicaid health insurance program. Operated by individual states and partly funded by the federal government, Medicaid is applicable to low-income individuals, including seniors and socioeconomically deprived patients like Hannah (Fay, 2012). Besides, Medicaid enables people to afford long-term services, such as nursing care, hospice care, and home-based care services, which Hannah requires. Medicaid has provisions that foster flexible care. For instance, the scheme increases healthcare efficiency and quality by supporting the CAPABLE model (Fulmer et al., 2021). Hence, Medicaid will better Hannah’s health and safety outcomes by offering funds to upgrade the patient’s residence and build more opportunities for home healthcare.
Regulatory Body Having Jurisdiction over One of the Facilities in the Scenario
The regulatory body that can manage the facilities in the scenario is the Centers for Medicare & Medicaid Services. This government agency is responsible for overseeing Medicaid and Medicare programs (Galan, 2020). The body manages healthcare-related provisions to help people afford quality care through various schemes. Hannah should secure packages managed by the CMS to pay for hospitalization, nursing care, total knee replacement, and other medical services mentioned in the scenario.
Regulatory Requirement to Ensure Organizational Compliance
A regulatory requirement pertaining to the case study is about adherence to the CMS’s guidelines. The care manager should ensure that the patient has satisfied eligibility requirements to access the benefits of the Medicaid program. Hannah should be residing in a state where she seeks Medicaid services. She must be an American citizen or permanent resident (Medicaid, n.d.). The care manager should submit Hannah’s details to Medicaid before admission or modifying the patient’s care coordination plan to ensure organizational compliance.
Educational Strategy to Discuss about the Chronic Illness and the Patient’s End-Of-Life Care
A likelihood of end-of-life care will require the HSC intern to employ a one-on-one educational strategy. The work colleagues and managers will hold honest conversations regarding the patient’s progress, chronic illness, and palliative care. After that, the interdisciplinary team must meet, engage, and educate Hannah’s friends and family members (Roberts et al., 2015). The health and social care staff should undergo training to gain knowledge about end-of-life care and the skills needed to manage the chronically-ill patient and communicate with her family.
How to Apply the Educational Strategy to the Population of My Choice
Healthcare practitioners should have effective communication skills to educate families of people with life-limiting illnesses through face-to-face discussion. They must comprehensively teach the population to help them understand all healthcare options, goals of end-of-life care, and how they differ from other treatment services (Roberts et al., 2015). Through effective communication, nurses would easily engage and educate the patient’s relatives and check whether they understand information about terminal-illness management. This strategy would enable healthcare providers to determine whether they provide education in an effective and comprehensible manner. Hence, the family members or caregivers would fully understand their roles, ways to administer medications, and how to comfort and accommodate Hannah.
Communication and Technological Practice
Technological advances have smoothened care delivery and helped improve patient outcomes. The interdisciplinary team will use communication and collaboration platforms for case management purposes. The Microsoft Teams platform would best promote information exchange among staff members, foster supportive efforts, and help deliver effective services (Gomes, 2021). This tool intends to improve clinical efficiency and productivity to facilitate the provision of high-quality care in a multifaceted healthcare environment (“Why Microsoft teams for the healthcare industry,” n.d.). With Microsoft Teams, healthcare practitioners utilize predictive analytics to make quicker decisions through effective collaboration and communication.
Proposed Plan of Care
The interdisciplinary team will use the Microsoft Teams tool to facilitate care delivery. The technological platform will make it easier for healthcare providers to engage in two-way communication and develop strategies to individualize and accommodate Hannah’s needs. Health practitioners will employ the Microsoft Teams program to provide patient education virtually, discuss issues, make informed decisions, coordinate Hannah’s care, and hold virtual meetings within one place. With this software application, healthcare professionals will interact, collaborate, and exchange Hannah’s electronic health records through secure messaging, calls, video conferencing, and screen sharing (Gomes, 2021; “Why Microsoft teams for the healthcare industry,” n.d.). The platform will optimize patient care provision by streamlining telehealth workflows and building a seamless environment for the team to store patient records, prioritize care coordination, and offer optimal care and support.
Technology Resources and One Communication Intervention for Care Continuation
The interdisciplinary team requires technological tools and communication intervention to continue with Hannah’s care. The necessary technology resources include electronic health records (EHR) portals and remote monitoring devices. Since Hannah has chronic illnesses, she needs these gadgets to facilitate continuous monitoring, proactive clinical decisions, and access her records in real-time. Automated alerts and reminders will be used as a communication intervention to ensure a continuum of care and support healthcare self-management (Perri-Moore et al., 2016). Communication through informatics interventions will help Hannah and her family obtain more information about COPD management, reduce frequent hospital visits, and integrate health behaviors into their day-to-day activities.
Role of the HSC in This Scenario
In this case study, the HSC should undertake different tasks and duties to coordinate care and ensure superior service delivery. They are responsible for pinpointing the best technique to evaluate the patient, determining factors affecting her health, and assessing her needs. These roles will involve setting appointments, collaborating with practitioners to devise and execute treatment plans, managing payment options, and coordinating providers’ efforts (Western Governors University, 2019). The HSC role will provide various benefits. Through the biopsychosocial approach, the HSC will empower the patient and accommodate her individual needs through active involvement and social interactions (Laborde, 2016). Further, Hannah and her family will receive education from the HSC, learning more about chronic conditions and how to manage them effectively. The HSC will build a superior healthcare system through care and effort coordination, helping secure medical funding, enhance efficiency and patient outcomes, and streamline clinical processes. Thus, the HSC will aid in crafting positive patient experiences through patient-centered practices and the best clinical decisions.
References
Centers for Disease Control and Prevention. (2021). About Social Determinants of Health (SDOH): What are social determinants of health? https://www.cdc.gov/socialdeterminants/about.html
Child Welfare League of America. (2021). Social determinants of health: Neighborhood and built environment. https://www.cwla.org/wp-content/uploads/2021/07/SDOH-One-Pager-Neighborhood-Built-Environment.pdf
Consequences of non-compliance in healthcare. (2020). Power DMS. https://www.powerdms.com/policy-learning-center/consequences-of-non-compliance-in-healthcare
Ernst, E. (2007). Holistic health care? British Journal of General Practice, 57(535), 162-163. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034187/
Fay, B. (2012). Senior Health Care Options and Costs. Debt. https://www.debt.org/medical/senior-options-costs/
Fulmer, T., Reuben, D. B., Auerbach, J., Fick, D. M., Galambos, C., & Johnson, K. S. (2021). Actualizing better health and health care for older adults: Commentary describes six vital directions to improve the care and quality of life for all older Americans. Health Affairs, 40(2), 219-225. https://doi.org/10.1377/hlthaff.2020.01470
Galan, N. (2020, March 3). What are Medicare and Medicaid? Medical News Today. https://www.medicalnewstoday.com/articles/what-are-medicare-and-medicaid
Gomes, N. (2021, April 29). Eight technologies practices are leveraging to deliver better patient care. Physicians Practice. https://www.physicianspractice.com/view/eight-technologies-practices-are-leveraging-to-deliver-better-patient-care
Kadivar, M., Manookian, A., Asghari, F., Niknafs, N., Okazi, A., & Zarvani, A. (2017). Ethical and legal aspects of patient’s safety: a clinical case report. Journal of medical ethics and history of medicine, 10(15). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6150915/
Laborde, S. (2016). Biopsychosocial Model, Bridging the gap between emotion and cognition: An overview. Performance Psychology, 275-289. http://dx.doi.org/10.1016/B978-0-12-803377-7.00017-X
Medicaid. (n.d.). Medicaid: Eligibility. https://www.medicaid.gov/medicaid/eligibility/index.html
Perri-Moore, S., Kapsandoy, S., Doyon, K., Hill, B., Archer, M., Shane-McWhorter, L., … & Zeng-Treitler, Q. (2016). Automated alerts and reminders targeting patients: a review of the literature. Patient education and counseling, 99(6), 953-959. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4912908/
Roberts, R., Moir, C., Martz, K., Perry, J., & Tivis, L. (2015). Communicating with patients and their families about palliative and end-of-life care: Comfort and educational needs of nurses. International journal of palliative nursing, 21(3), 109-112. https://doi.org/10.12968/ijpn.2015.21.3.109
Shrank, W. H., DeParle, N. A., Gottlieb, S., Jain, S. H., Orszag, P., Powers, B. W., & Wilensky, G. R. (2021). Health costs and financing: Challenges and strategies for a new administration: Commentary recommends health cost, financing, and other priorities for a new US administration. Health Affairs, 40(2), 235-242. https://doi.org/10.1377/hlthaff.2020.01560
Western Governors University. (2019, September 4). What does a health care coordinator do? https://www.wgu.edu/blog/what-does-health-care-coordinator-do1908.html
Why Microsoft teams for healthcare industry? (n.d.). EPC Group. https://www.epcgroup.net/microsoft-teams-for-healthcare-industry/
