NURS FPX 4015 Assessment 3: Planning and Presenting a Care Coordination Project
Introduction
Effective care coordination ensures that patients receive seamless, high-quality healthcare services NURS FPX 4015 Assessment 3 across different settings and providers. This assessment focuses on designing and presenting a care coordination plan for a patient population—older adults with chronic heart failure (CHF)—to improve outcomes, reduce hospital readmissions, and enhance quality of life.
Identified Health Concern
Chronic heart failure is a leading cause of hospital admissions among older adults, with high readmission rates due to poor self-management, medication nonadherence, and limited follow-up care. Effective care coordination can bridge these gaps by improving communication between patients, families, and healthcare teams.
Project Goals
Improve patient self-management of CHF.
Reduce 30-day hospital readmission rates by at least 20%.
Enhance patient and family engagement in care planning.
Evidence-Based Intervention
The proposed intervention is a Comprehensive Heart Failure Management Program that includes:
Individualized care plans based on patient needs.
Regular follow-up calls from a nurse care coordinator.
Patient and caregiver education on diet, medication, and symptom monitoring.
Collaboration with cardiologists and primary care providers for treatment adjustments.
Evidence from the American Heart Association supports coordinated care models to improve heart failure outcomes.
Interprofessional Collaboration
The program involves:
Nurses: Monitor symptoms, provide education, and track progress.
Cardiologists: Optimize treatment plans.
Pharmacists: Ensure medication accuracy and adherence.
Dietitians: Create low-sodium diet plans.
Social Workers: Assist with transportation, home support, and resources.
Presentation Plan
The project will be presented using:
A PowerPoint presentation highlighting problem statistics, intervention steps, and expected outcomes.
Infographics summarizing patient benefits and care flow.
Case study examples demonstrating real-world application.
Expected Outcomes
Reduction in CHF readmissions.
Improved patient satisfaction scores.
Increased knowledge of CHF management among patients and caregivers.
Conclusion
By implementing a structured, interprofessional CHF management program, healthcare providers can improve outcomes, reduce costs, and enhance patient quality of life through effective care coordination.
NURS FPX 4015 Assessment 4: Patient, Family, or Population Health Problem Solution
Introduction
High rates of Type 2 Diabetes Mellitus (T2DM) in underserved urban communities NURS FPX 4015 Assessment 4 continue to drive preventable complications and healthcare costs. This assessment outlines an evidence-based solution to address T2DM through a Community-Based Diabetes Self-Management Program (DSMP) supported by telehealth.
Problem Overview
Low-income and minority populations experience disproportionate T2DM prevalence due to barriers such as poor access to healthy foods, limited health literacy, and lack of consistent care. Without targeted interventions, patients face heightened risks of complications including cardiovascular disease, kidney failure, and amputations.
Proposed Evidence-Based Solution
The DSMP will include:
Weekly group education sessions on nutrition, exercise, and medication management.
Telehealth check-ins for ongoing support.
Culturally tailored diet plans reflecting local food availability.
Peer support groups to enhance motivation.
Research demonstrates that structured self-management programs significantly improve glycemic control and reduce hospital admissions (Chrvala et al., 2016).
Implementation Plan
Phase 1 – Preparation: Recruit participants via community outreach, assess baseline health metrics, and train facilitators.
Phase 2 – Execution: Conduct group sessions, biweekly telehealth calls, and distribute multilingual resources.
Phase 3 – Evaluation: Measure changes in HbA1c, BMI, medication adherence, and participant satisfaction.
Interprofessional Collaboration
The project team will include:
Nurse educators for program delivery.
Dietitians for individualized meal plans.
Pharmacists for medication reviews.
Social workers to address socio-economic barriers.
Community leaders for participant engagement.
Expected Outcomes
At least a 1% reduction in average HbA1c levels within six months.
Increased patient confidence in managing T2DM.
Fewer emergency visits for diabetes-related complications.
Evaluation Methods
Quantitative: HbA1c, BMI, and adherence rates before and after the program.
Qualitative: Surveys and focus groups to assess satisfaction and perceived benefits.
Conclusion
The DSMP offers a sustainable, culturally sensitive approach to addressing T2DM in underserved communities. Through education, telehealth, and collaborative care, the program can significantly improve health outcomes and reduce disparities.
