In South Bend, Indiana, there is an extended care institution called Healthwin Specialized Care that focuses on treating complicated medical disorders. The hospital treats a wide range of patients, including those who have many co-morbidities, chronic illnesses, and those who need rehabilitation after suffering a serious illness or injury. In addition, numerous medical specialists, including doctors, nurses, therapists, and social workers, work at the hospital.
The inter-professional team plan of care was found to be the gap at the point of care in Healthwin Specialized Care. This was identified with the assistance of Julie, the hospital’s nurse manager who has been employed by Healthwin for more than ten years, through a study of patient outcomes and a staff questionnaire. Julie, who has a Master of Science in Nursing, has significantly changed how the facility operates when she first joined as an intern. The target audience for this project is the healthcare team at Healthwin Specialized Care, including physicians, nurses, therapists, and social workers. The project will also target patients and their families, as well as other healthcare team members, such as case managers and care coordinators.
To address the gap in care identified at Healthwin Specialized Care, an interprofessional team will be assembled to design, participate in, and implement a coordinated, patient-centered care plan. The team will be led by Julie, who will serve as the facilitator. The team will include representatives from various disciplines, such as nursing, medicine, therapy, social work, and other relevant specialties. The team will begin by conducting a thorough assessment of the patient’s needs, including gathering information from the patient, their family, and other healthcare team members.
The care plan will be reviewed and discussed with the patient and their family and will address their concerns and goals. The plan will also include clear goals and objectives and a schedule for monitoring progress. This will ensure that all healthcare team members are aware of the patient’s needs and are interested in the care plan. The facilitator, Julie, will also ensure that the patient and their family are provided with education and resources to help them better understand and manage their condition.
Implementing the interprofessional team plan of care will involve several key steps. First, the team will conduct training for all healthcare team members on the new plan of care, including the roles and responsibilities of each team member (Baird et al., 2019). The team will also establish clear communication channels, such as daily huddles, to ensure that all team members know the patient’s status and any necessary adjustments to the care plan.
The team will also establish a system for monitoring progress and tracking outcomes, including patient satisfaction, length of stay, and readmissions. This information will be used to adjust the plan of care as needed and ensure that the team is meeting its goals and objectives (Baird et al., 2019). Finally, the team will provide ongoing education and support for patients and their families, including information about medications, therapy, and other treatments.
The project applies the DIKW framework (Data, Information, Knowledge, Wisdom) by gathering data on patient outcomes and staff feedback to identify the gap in care. This data is then analyzed and used to develop a plan of care that addresses the identified issues. The National Patient Safety Goals (NPSGs) that correspond to Healthwin Specialized Care’s multimodal team care plan initiative are as follows:
• Goal 1: Promote patient recognition reliability. The project will prioritize implementing a comprehensive patient identification process, which will include using unique identifiers such as the patient’s name and medical record number and using pictures or fingerprints to validate the patient’s identity.
• Goal 2: Enhance caregiver engagement efficiency. The project will prioritize establishing a clear communication mechanism, such as daily huddles, to guarantee that all team members are aware of the patient’s state and any necessary changes to the plan of care.
Reference
Baird, J., Ashland, M., & Rosenbluth, G. (2019). Interprofessional teams. Pediatric Clinics of North America, 66(4), 739–750. Web.