Prof. Name

Date

Patient Discharge Care Planning

This assessment is based on a patient scenario named Marta Rodriguez, who had a car accident in Nevada. As a freshman in the first semester of college, Marta had gained a student health insurance plan and was acquiring care in the nearest shock trauma center for the past four weeks. However, she was recently moved from New Mexico to Nevada to study. Marta underwent several surgeries and antibiotic treatment against systemic infection.

The patient’s native language is Spanish, while English is her second language. As a senior care coordinator overseeing Marta’s care treatments, analyzing the key issues that interprofessional team members must delve into to ensure effective discharge care planning for patients is imperative.

Therefore, I will present Marta’s case in an upcoming interprofessional team meeting to discuss the careful discharge plan with a coordinated care approach. This will require meaningful use of Health Information Technologies (HIT) to enable care coordination and continuity of care in the discharge planning. Moreover, the plan will discuss data reporting ways and their impact on care management and clinical efficiency. Lastly, the plan will discuss how the patient-reported health information can enhance the patient’s health outcomes.

 Longitudinal Patient Care Plan

HIT plays a significant role in smooth care transitions and the continuum of care after patient discharge. These innovative technological alternatives to traditional in-person care can promote remote monitoring and virtual follow-up appointments (Abraham et al., 2022). In Marta’s case, interprofessional team members can use Electronic Health Records with multilingual capabilities to create and maintain a concise and thorough digital record of the patient’s medical history and treatment plans.

This will include her shock trauma center stay, surgeries, and antibiotic treatment histories (Khoong et al., 2020). The healthcare professionals will use this platform to access real-time data about Marta’s health status. This will facilitate collaborative decision-making and ensure continuity of care across different healthcare settings (Khoong et al., 2020). 

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 pas