NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

The interprofessional team will integrate telehealth platforms and remote monitoring tools to monitor Marta’s recovery progress post-discharge. This includes virtual follow-up appointments, medication adherence tracking, and vital sign monitoring. Telehealth services with remote monitoring elements will enhance patient engagement and allow the team to address emerging health concerns proactively. These tools will provide real-time data on Marta’s health status post-discharge, enabling early detection and intervention to prevent potential complications (Somsiri et al., 2020).

Furthermore, predictive analysis tools and Clinical Decision Support Systems (CDSS) will be used to assess Marta’s risk of readmission based on several factors, such as post-operative recovery, infection risks, and adherence to treatment plans. Interprofessional teams will use these tools to identify the potential causes before they escalate and allow timely targeted interventions. The decision support systems will assist healthcare providers in making evidence-based decisions for Marta’s specific health needs and minimize the risk of readmission (Oosterhoff et al., 2021).

Logical Implications of HIT in Care Planning  

These HIT elements collectively contribute to a comprehensive and patient-centered care plan, reducing the risk of readmission within 48 hours post-discharge. With the help of real-time data access, continuous monitoring, and virtual consultations, interprofessional team members can promptly identify and address any potential issues with enhanced patient engagement (Srinivasan et al., 2020).

Additionally, through EHR use and CDDS, care coordination will be improved due to better communication and collaboration. This will foster a holistic care approach to facilitate a continuum of care for Marta’s post-discharge care. Hence, using HIT tools supports longitudinal and patient-oriented care plans by enhancing interprofessional care coordination and patient empowerment (Somsiri et al., 2020).

Consequences of Using Specific Data and Information

By using specific health-related data and information, such as acknowledging the language barrier and implementing interpretation technology to ensure accurate and clear communication, patient engagement will be enhanced, and adherence to treatment plans in Marta’s case will be facilitated. Moreover, using past medical history data and treatment plans, Marta’s ongoing care will be better aligned, reducing the chances of treatment errors, hospital readmissions, and emergency visits (Abraham et al., 2022). Lastly, using the information on Marta’s health insurance plan, billing processes for Marta’s care will be streamlined, and insurance-relevant delays can be avoided.

Data Reporting Pertinent to Client Behaviors

Reporting health-related data is significant in ensuring smooth care coordination and improving health outcomes. Moreover, data reporting within healthcare settings promotes efficiency in clinical practice and interprofessional innovation in care treatments. Following are the three ways in which data reporting can impact care coordination, clinical efficiency, care management, and interprofessional creative idea development:

• By analyzing data related to Marta’s behaviors, such as medication adherence and follow-up attendance, the care coordination team can tailor the care coordination approach related to procured information. For example, suppose reported data indicates inconsistent medication adherence (Kumar et al., 2022). In that case, the healthcare team can implement targeted interventions such as medication reminders or educational resources in Spanish to address potential language-related barriers. This tailored approach will improve care coordination and care management by addressing specific challenges Marta faces. The team can allocate resources effectively and ensure tailored interventions suit her unique health needs (Kumar et al., 2022).
•  Data-driven insights from reported data on Marta’s health can also enhance clinical efficiency by analyzing post-operative and post-discharge recovery progress, pain levels, and following rehabilitation exercises. Suppose data suggests slower-than-expected recovery or signs of discomfort. In that case, the healthcare team can adjust the care plan and schedule follow-up appointments to enhance clinical efficiency and provide timely and targeted care (Richards et al., 2020).

NURS FPX 6612 Assessment 3 Patient Discharge Care Planning

• Analyzing data on communication preferences and engagement with culturally diverse patients can shape interprofessional innovative solutions. By assessing Marta’s communication preferences, patient satisf