Improved Transition Management: Ethnically Diverse Patients with Chronic Conditions

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Table of Contents

Impact of Health Care Technology
Care Coordination and the Use of Community Resources
State Board Nursing Practice Standards and Governmental Policies
Meeting with the Patient
Reviewed EBP Documents
Exploration of the Effects of the Problem
Volunteer Experience Form
References

Impact of Health Care Technology

Chronically ill patients face many challenges, such as lifestyle modifications and medication management, and health care technology can provide them with high-quality, engaging care. Specific technologies used for preventing readmissions in these patients include remote monitoring systems, telehealth apps, and wearable devices. Remote patient monitoring systems have become important to reduce hospital readmissions, enabling healthcare professionals to monitor patients’ vitals using various tracking devices (Hewner et al., 2018). These devices allow for monitoring pulse, blood pressure, blood oxygen saturation, body temperatures, or even blood sugar levels for patients with diabetes. After the patient’s health metrics are received in real-time, they are recorded by the system in the hospital database. Notifications are sent to physicians when patients’ vitals get non-typical, and immediate medical assistance is accorded. One study showed that the hospital could reduce readmissions by up to 78% when they introduced a telemedicine app (Samal et al., 2021). The app was set to remind patients regularly to record their vitals, such as blood pressure, blood oxygen saturation, and other symptoms experienced.

Evidence shows that incorporating telemedicine apps for video conferencing is an effective way to stay in touch with patients. This provides opportunities for immediate assistance despite the patients’ distance from their caregiver. Patients can also schedule their hospital appointments or get clarifications on their medication plans without physical hospital visitations (Hewner et al., 2018). With such help in patient monitoring, unplanned readmissions are decreased. Patient engagement software has helped reduce readmissions by aiding in educating patients about their illnesses and post-discharge self-care (Hewner et al., 2018). For example, patients can watch videos demonstrating how to dress wounds, inject insulin, take vitals, and do many other procedures.

Finally, wearable devices are of great use for patients with chronic conditions because of their ease of use and the ability to track vital signs. Examples of this technology are monitors that can track heart rate, blood glucose levels, oxygen saturation of blood, or breathing rate and depth and can be worn on wrists, hands, ears, chest, and other body parts (Guo et al., 2021). These devices can help identify the deterioration of a health condition early and assist in making diagnosis and treatment decisions (Guo et al., 2021). Yet, this technology has disadvantages when applied to chronically ill patients. Wearable devices are not helpful in the management of chronic conditions such as diabetes because they do not lead to a significant decrease in blood pressure, cholesterol levels, or patients’ weight (Jo et al., 2019). Thus, although this technology can assist physicians in monitoring patients’ vital signs, establishing a diagnosis and developing treatment plans, it does not motivate patients to self-manage their chronic conditions.

The evidence is consistent with technology use in my nursing practice. For example, I have seen patients using wearable devices to track their body temperature and heart rate. I have also witnessed the use of telehealth: physicians used videoconferencing to consult patients from remote areas who were unable to travel to the hospital. The use of technology in health care can also be noticed in the broader nursing practice. For instance, the University of Kansas Health System reduced hospital readmissions for patients with diabetes by up to 11% after the introduction of predictive analytics tools (Hewner et al., 2018). This analytics technology and supervised follow-up programs effectively reduced post-discharge situations and the rate of readmissions. The predictive analytics tools ensured that the patient and care manager were prepared and ready to deal with symptoms whenever they surfaced.

There are some barriers and costs associated with the use of healthcare technology. For example, in the case of automated medication delivery equipment, factors like fear, utility, time, legality, and complexity act as roadblocks to wider adoption. In a clinical setting, the price of automated technologies for managing type 2 diabetes may also be an impediment (Camicia et al., 2021). Healthcare professionals must consider the cost in this scenario because the machines have been labeled expensive. It is important to weigh the use, need, and value of the machine before purchasing because the cost of it may increase despite the continued importance of the technology it provides. Patients with type 2 diabetes who take advantage of bar code technology and automated medicine dispensing machines generally receive better care.

Care Coordination and the Use of Community Resources

Clinicians, hospital systems, managed care companies, and governmental organizations participate in care coordination. Care coordination includes case management services and discharge planning (Dye et al., 2018). Among the interventions used in case management to assist people in navigating the complexities of the healthcare system are referrals from primary care providers. Identifying members at higher risk for future increased health care utilization through analytics, transition support, coordination between healthcare providers, transportation coordination, and other measures.

Along with teaching members, caregivers, and families how to manage their health and well-being, care coordination also includes supporting a prescribed medication schedule (Dye et al., 2018). The exchange of information (such as medical records, referrals, and authorizations) and the transition of care are essential to care coordination efforts, especially as patients interact with various independent healthcare organizations in charge of their care. Appropriate transition management has improved individual outcomes and lowered readmissions to hospitals. Patients in primary care, particularly those with chronic conditions, have unmet basic needs in the community (Liang et al., 2021). The patients struggle to meet basic needs like access to affordable healthcare, food, and shelter. Patients with chronic diseases experience better healthcare results when these needs are met.

State Board Nursing Practice Standards and Governmental Policies

Delivering high-quality, safer healthcare to patients is the primary focus of nursing practice standards set by state boards and other governmental or company rules. Liability law in the nursing profession is a set of rules established by governments and nursing organizations to safely and effectively use healthcare technology. The policy’s overarching goal is to eradicate the issue of carelessness in the application of healthcare IT. Clinicians try their best to avoid making mistakes contributing to the opioid crisis by adhering to the principles of carelessness they have been taught (Arundel et al., 2019). This approach has been helpful in the fight against hypertension in the United States by making nurses more vigilant about not taking on responsibility for cases of chronic disorders.

Many professionals, each with their own unique set of skills and perspectives, participate in care coordination. Professionals may disclose their original, patent-pending ideas during the care coordination process. Intellectual property rights are one government policy that helps ensure that healthcare is coordinated effectively and safely. Policymakers have instituted protections for intellectual property to ensure that original authors receive credit for their work and benefit from any uses that may be made of it. Care coordination among healthcare stakeholders has improved due to this legislation, and people no longer have to worry about their work being used without their permission (Arundel et al., 2019). Intellectual property rights policies, like nurse liability law, have helped to ensure the highest level of professionalism among nurses.

Meeting with the Patient

During this practicum, I met with Mr. Davies, a 65-year-old African American diagnosed with type 2 diabetes. During the communication with this patient, I learned that he presented to the primary care unit two months ago with hyperglycemia and generalized weakness. He was prescribed Glucophage and was instructed to take insulin shots. However, the patient said that he stopped taking Glucophage after his refills ran out and did not take insulin because these medications were not covered by his insurance. Although, at discharge, the patient was given a glucometer to measure blood sugar levels, he found this device uncomfortable and did not use it. The patient stated that he did not do physical exercise and did not adjust his diet to his condition. As a result, he was readmitted to the hospital with hyperglycemia, which is when I met him.

The patient noted that he did not use smartphone applications or telehealth to control his problem and did not consult any websites about diabetes. He explained this behavior by a lack of technological skills. Care coordination was used to a small extent: he was only referred to a dietician, but he did not make an appointment. The patient has a car, so a lack of transportation to the problem-related appointments was not an issue. Mr. Davies denied being referred to support groups or religious institutions.

Reviewed EBP Documents

From the multiple resources available, I chose two evidence-based documents pertaining to the problem of readmissions in patients with chronic conditions. From the first source, I found out that the 30-day readmission rate for diabetes is 20.3%, and these readmissions result in the total cost of 251 million (“Guide to reduce disparities,” 2018). I also learned that African Americans are affected by diabetes two times more often than whites and are more likely to have lower extremity amputations (“Guide to reduce disparities,” 2018). These findings suggest that African Americans with diabetes are in a pressing need for high-quality multidisciplinary care, culturally tailored health interventions, and a response to social determinants of health. From the second source, I learned strategies for care coordination for patients with chronic conditions. These strategies include patient education, medication reconciliation, and the provision of co-located health professionals (“Care coordination toolkit,” 2019). Furthermore, in individuals affected by social determinants of health, challenges should be determined and referrals to social workers and other community resources should be considered (“Care coordination toolkit,” 2019). The review of these documents indicated that I needed to identify and address challenges faces by my patient.

Exploration of the Effects of the Problem

By interacting with this patient, I explored the effects of readmissions on the quality and costs of care and patient safety. In terms of quality, I found that readmissions were the result of poor discharge planning and patient transition from hospital to home. The patient was rehospitalized because he did not get sufficient education about the importance of controlling his blood sugar levels and the use of a glucometer. Regarding safety, addressing the risk of readmissions is vital for ensuring patient safety because patients tend to return to hospitals in a worse state than during their initial admission. Finally, in the given case, healthcare professionals have not considered the patients’ costs of treatment. As a result, the patient could not afford medications to control his condition, leading to his readmission and increased costs for the healthcare system.

My plan to address the problem changed based on my experience. First, I believed that providing thorough patient education would help to tackle the issue. However, after interacting with the patient, I realized the importance of referring ethnically diverse patients to community resources. This is because, even if educated, patients like Mr. Davies cannot afford the prescribed treatments and may need additional community support to adhere to medications. One thing that surprised me was that healthcare professionals might not consider patients’ individual circumstances when developing treatment plans. This was unexpected because the evidence points to the importance of social determinants to patients’ health outcomes. Therefore, a failure to address them may increase the chance of readmissions in chronically ill individuals.

Volunteer Experience Form

Site Contact Information

Direct Care Contacts: Arthur James Davies
Direct Care Contact Relationship: Community member
Direct Care Contacts Email Address: [email protected]
Direct Care Contact Telephone: 404-434-3053

Volunteer Experience Total Hours

Total number of direct patient care hours: 2 hours:

Comment: There were three meetings lasting from 30 to 50 minutes.

Volunteer Experience

How were your volunteer hours spent: option 1 – talking or meeting with the patient.

Comment: I met with the patient at the hospital where he was readmitted after a failure to adhere to the previously prescribed treatment for diabetes. We held three meetings, each of which lasted for 30-50 minutes. At the first meeting, we became acquainted, and the patient introduced his problem to me. At the second encounter, I watched the nurse administer medications to the patient and then talked to Mr. Davies about his previous treatments. Finally, we met to discuss the patient’s lifestyle modifications and the use of technology and community resources.

Site Contact Acknowledgment

I give the university my permission to contact my practicum patient.

References

Arundel, A., Bloch, C., & Ferguson, B. (2019). Advancing innovation in the public sector: Aligning innovation measurement with policy goals.Research Policy, 48(3), 789-798. Web.

Camicia, M., Lutz, B., Summers, D., Klassman, L., & Vaughn, S. (2021). Nursing’s role in successful stroke care transitions across the continuum: From acute care to the community.Stroke, 52(12), e794-e805. Web.

Care coordination toolkit. (2019). Centers for Medicare & Medicaid Services. Web.

Dye, C., Willoughby, D., Aybar-Damali, B., Grady, C., Oran, R., & Knudson, A. (2018). Improving chronic disease self-management by older home health patients through community health coaching. International journal of environmental research and public health, 15(4), 660. Web.

Guide to reduce disparities in readmissions. (2018). Centers for Medicare & Medicaid Services. Web.

Guo, Y., Liu, X., Peng, S., Jiang, X., Xu, K., Chen, C., Wang, Z., Dai, C., & Chen, W. (2021). A review of wearable and unobtrusive sensing technologies for chronic disease management. Computers in Biology and Medicine, 129, 104163.

Hewner, S., Sullivan, S. S., & Yu, G. (2018). Reducing emergency room visits and in‐hospitalizations by implementing best practices for transitional care using innovative technology and big data. Worldviews on Evidence‐Based Nursing, 15(3), 170-177.

Jo, A., Coronel, B. D., Coakes, C. E., & Mainous III, A. G. (2019). Is there a benefit to patients using wearable devices such as Fitbit or health apps on mobiles? A systematic review. The American Journal of Medicine, 132(12), 1394-1400.

Liang, H. Y., Hann Lin, L., Yu Chang, C., Mei Wu, F., & Yu, S. (2021). Effectiveness of a nurse‐led tele‐homecare program for patients with multiple chronic illnesses and a high risk for readmission: A randomized controlled trial.Journal of Nursing Scholarship, 53(2), 161-170. Web.

Samal, L., Fu, H. N., Camara, D. S., Wang, J., Bierman, A. S., & Dorr, D. A. (2021). Health information technology to improve care for people with multiple chronic conditions.Health Services Research, 56, 1006-1036. Web.

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