Because of technological improvements, diverse specializations, and the way health services are organized, health care systems have undergone constant change.
As a result, there is a need to adapt to these changes in order to improve patient care delivery and provide favorable patient outcomes. A lack of efficient coordination in such complex medical systems may have an impact on its delivery, particularly for patients with chronic diseases like heart failure (HF). The global prevalence of heart failure has increased; a study published in the Journal of the American Medical Association revealed a 24.8% increase in HF readmission rates between 2007 and 2009. (Veenstra, op den Buijs, Pauws, Westerterp, & Nagelsmit, 2015).
Proper coordination would allow wiser decision making by the health practitioners, eliminate duplication of services, and in turn, improve the overall quality of health care services.
This health care coordination plan addresses the issues related to chronic illnesses like heart failure. The plan aims to make the clinic reach the capacity of enrolling more than 90% of patients with heart failure condition for both primary and secondary care. The paper also indicates the plan to reduce readmission rates by about 5% and the ways of achieving a coordinated discharge and care plan.
Communication and Follow-Up Of a Patient after Discharging
The reason why most clinics lack coordinated care for a critical condition such as heart failure is that the practitioners dwell on patient care while within the institution with no follow up on the patient afterward. Lack of data integration has also been identified as an issue affecting the success of coordinated care (Veenstra, op den Buijs, Pauws, Westerterp, & Nagelsmit, 2015). Our team will be comprised of both inpatient and outpatient Cardiologists and nurses, therapists and palliative care who are confined within the heart failure department. The heart failure coordination plan will be discussed and be implemented by the team members within two weeks. The implementation will take place in phases beginning with the current and the previous HF patients who visited the clinic.
The retrospective health records regarding a patient on demographics, physical examination and treatment data of a patient are necessary while handling a patient.
The team will ensure that the patients’ information is available electronically to facilitate efficient transfer of clinical information from one practitioner to another (Aller et al., 2015). The heart failure management plan will require a team of data analysts who will get information from the patient data warehouse and post it to HF dashboards for analysis. The data will be used in patient monitoring to analyze their performance, generate, and deliver reports on particular patients. The data dashboards will also project any patient behavioral changes, detect possible risks and ease the process of identifying the type of health care service required (Aller et al., 2015). Upon the implementation of the plan, the team members will measure the outcome of the program using the Patient-Reported Outcomes Measurement Information Systems (PROMIS). The system will give the report on the patient’s well-being on physical, mental status to be able to determine the outcome of the care.
Medication Therapy and Safe Discharge
The transition process while discharging the patients will also require home care and coordination with the team of practitioners. The clinic will implement safe discharge plan that ensures continuous patient care while at home and proper medication therapy. The plan will be achieved by constant communication between the nurses within the team, the patient, and the family which may be through conferences or home visits (Berry, Rock, Smith Houskamp, Brueggeman, & Tucker, 2013). A few nurses will be placed in charge of outpatient care to the discharged heart failure patients and also ensure the patient diet and medication compliance. The nurses will work together with the family to make sure that the patient takes in the right food portions, do regular exercise, and get the necessary support.
Patient Education
The clinic will offer educational systems such as telehealth to the patients to provide home-based health education, remind the patients on medications and safety measures to take (Aller et al., 2015). The system will also offer dietary and motivational information to encourage the patients to adopt a healthy lifestyle. The change in patient behavior and the education will promote self-management of conditions such as blood pressure or diabetes. This type of system will significantly reduce the rate of readmissions and redundancy in primary care services. Furthermore, the system will offer patient surveillance and hence give room for timely response to any deviations from the norm. Besides the systems, the nurses will provide videos and face to face education programs and interviews to ensure that the patients have the knowledge and apply in enhancing their wellbeing.
Conclusion
The implementation of the Heart Failure Coordination plan will see the reduction of readmission percentages by 5% and also increase the quality of service in heart failure patients follow up programs. The program will also support 100% compliance with the patient education and offer safe discharge transition. The process of monitoring the patient performance will be facilitated to determine the outcome of the plan, the credibility, and the impact of the decisions made by practitioners hence improve the overall health care delivery.
References
Aller, M., Vargas, I., Coderch, J., Calero, S., Cots, F., & Abizanda, M. et al. (2015). Development and testing of indicators to measure coordination of clinical information and management across levels of care. BMC Health Services Research, 15(1). http://dx.doi.org/10.1186/s12913-015-0968-z
Berry, L., Rock, B., Smith Houskamp, B., Brueggeman, J., & Tucker, L. (2013). Care Coordination for Patients With Complex Health Profiles in Inpatient and Outpatient Settings. Mayo Clinic Proceedings, 88(2), 184-194. http://dx.doi.org/10.1016/j.mayocp.2012.10.016
Veenstra, W., op den Buijs, J., Pauws, S., Westerterp, M., & Nagelsmit, M. (2015). Clinical effects of an optimised care program with telehealth in heart failure patients in a community hospital in the Netherlands. Netherlands Heart Journal, 23(6), 334-340. http://dx.doi.org/10.1007/s12471-015-0692-7
