Community Resources and Best Practices

Slide 2: Good day, everyone. My name is  _____. In this presentation, I will talk about what can be done and what can go wrong in composing the care for senior diabetic patients living in a particular area the Lakeside Heights suburb. To be a practice leader, aiming at promoting quality care coordination, you should know what exactly is wanted, how it is possible to support these wants, the ethical and legal implications of the whole process, and how to develop ideas to achieving those goals (Ford et al., 2021). This is a clear implication that quality outcomes improvement requires a good use of healthcare information systems in the process. According to the present knowledge about care coordination, a leader in this field should be capable of evaluating and analyzing change using data analysis. These are concerns that I will assess and from research propose solutions for enhancing care coordination in Lakeside Heights with due regard to the legal and ethical considerations.

Ethical Issues in Using Health Care Information Systems for Care Coordination

Slide 3: Lakeside Heights Health Network that is a regional medical facility is managing diabetic older individuals using a variety of health information systems, such as MedConnect and CareLink. These solutions are meant to help abstract patients’ data and enhance the communication of care between medical personnel.

Specific Situation and Current Resources

This is because resources such as the resources include the Lakeside Community Wellness and the Lakeside Diabetes Support Group Center involve sharing information, offering assistance, and organizing wellness programs hence form a central part of patient care (Sahu et al., 2022). Prescription schedules and blood glucose monitoring are two areas where care delivery commonly creates disjointed care and communication breakdowns irrespective of available resources. Besides the dilution of the standard of care, these problems raise significant ethical and legal concerns related to the patient’s rights to privacy and data protection, as well as equal access to healthcare.

Legal and Ethical Issues

In efforts to enhance coordinated treatment health care information systems used in care coordination pose the following ethical questions. Another one is the patient privacy. The unauthorized disclosure of such data or violation of privacy can occur where many providers have access to and modify patient’s records. Healthcare organizations must have safeguards to protect patients’ information according to the HIPAA law but putting it into practice can be challenging since healthcare institutions have elaborate IT systems (Sahu et al., 2022). Since patient information should be kept private and complete for trust and the right care to be provided, the security of data is an ethical issue. It is unethical for individuals to be denied equal health care regardless of their gender Charity. 

From the legal perspective, the implementation and utilization of health care must possess many rules and regulations that have to be followed. Lack of proper data protection policy may lead to legal problems, and this may lead to legal consequences such as possible legal actions or fines (Sahu et al., 2022). Furthermore, changes in the approaches to care coordination could impact society overall, therefore warranting a review and planning to deal with legal implications. Another legal issue is to ensure that patients as well as the health care providers consent to such use and are aware of its implications.

Evaluating Legal Issues in Care Coordination for Elderly Diabetic Patients

Slide 4: An evaluation of this case based on the care coordination methods used for senior diabetic patients in the Lakeside Heights suburbs exposes some critical issues from a legal perspective. One important issue is the ability to operate in compliance with regulations stated by HIPAA, in particular, patients’ right to privacy. With the current processes in place which allow several healthcare practitioners to access and update EHRs the privacy of patient data may be compromised if not well handled (Wakefield et al., 2020). Possible legal consequences for noncompliance might include penalties, lawsuits from impacted patients, and harm to the healthcare organization’s reputation. Security measures that ensure that all aspects of the patient data are guarded require observing the HIPAA guidelines on all the health information systems, including MedConnect and CareLink. Special attention should be paid to the regulation of patient data availability and accessibility.

All of the changes made to the processes of care coordination have to be considered in terms of the legal implications of the actions to avoid any negative consequences. To sustain perpetuity HIPAA compliance, security arrangements need to be given much thought when implementing new HISs or creating changes to the current ones. Legal reviews should comprise assessing how these systems safeguard their patients’ information and identifying gaps (Karamet al., 2023). They also have to consider legal consequences related to the patient’s consent to make sure that patients are informed regarding the use and sharing of their data. Proper orientation of health care workers to the new systems as well as the new regulations in the system would help lessen the likelihood of misuse of the system and information that may lead to legal implications for the practitioners. Healthcare administrators in Lakeside Heights can ensure and design highly optimal care processes in the management of diabetic elderly patients pointing at patient autonomic, successful flow of care, and methods of compliance with the regulations.

Comparing Current Outcomes to Best Practices

Slide 5: In the suburban community of Lakeside Heights, the current methods of care coordination for senior people with diabetes frequently result in fragmented care and communication gaps. These problems make it more difficult to effectively manage blood glucose monitoring and medication schedules (Karamet al., 2023). Current research shows that the finest care coordination strategies greatly enhance patient outcomes. For example, by enhancing provider-to-provider communication and streamlining patient data management, It has been shown that integrated care models that make use of contemporary health information systems enhance patient continuity of care and reduce hospitalization rates among patients with diabetes.

The importance of employing evidence-based interventions and putting the patient at the center of care is emphasized by best practices. A study on the use of methylenefibrate to lower cardiovascular risk in people with diabetes showed that patient data-driven focused therapies may improve outcomes (Karamet al., 2023). Implementing integrated health information systems and evidence-based interventions can result in major gains when comparing these best practices with the results that Lakeside Heights is now seeing. Better glucose control, fewer emergency room visits, and increased patient satisfaction are some of the gains. Healthcare executives should support these changes by making sure that all legal and ethical requirements such as those about patient privacy and data security are met to foster confidence and provide long-lasting results. 

Identifying an Appropriate Evidence-Based Intervention

Slide 6: Implementing a complete diabetes management program that combines telemedicine with routine in-person visits is an evidence-based intervention that is beneficial in improving care coordination for older diabetic patients in Lakeside Heights (Walton et al., 2022). Recent research has shown that when telemedicine is used in conjunction with conventional care, it can greatly enhance glycemic control and lower the number of hospital admissions among senior diabetic patients. While in-person appointments guarantee comprehensive physical examinations and individualized care plans, telemedicine enables ongoing monitoring and prompt actions. By combining the best features of both modalities, this hybrid approach offers patients comprehensive, ongoing care.

Stakeholders and Interprofessional Teams

Slide 7: While enabling patients to have better control over their diabetes through self-management support, this intervention targets the following stakeholders; Patients, Community-based organizations, Health care providers, and facilities. The role of Organisation for and in Care: to achieve the aims important endocrinologists, and other healthcare professionals such as general practitioners, nurses, and nutritionists are paramount. Thus, they are charged with the responsibility of designing the intervention and operation and management of the intervention (Vimalananda et al., 2023). Some of the support services provided in the community include education and health-related activities that are provided by the Lakeside Community Wellness Center and Lakeside Diabetes Support Group. The intervention ensures holistic and integrated care that harnesses and supports the medical, social, and emotional needs of senior diabetic patients by engaging other stakeholders. They also reduce the number of healthcare costs and increase patients’ satisfaction and overall quality of health.

Roles of Stakeholders and Interprofessional Teams in Diabetes Care Coordination

Slide 8: In Lakeside Heights, the programs aimed at improving the diabetic elderly care coordination and management generally rely more on the healthcare providers. Some of the stakeholders are endocrinologists, doctors, nutritionists, pharmacists, and nurses. The patient targeted has a special kind of ailment that each specialist that a patient has to see has a specific niche for and handles one component of diabetes (Northwood et al., 2023).  For example, primary care physicians are in charge of their patient’s overall health and coordinate the patient’s access to specialists. Endocrinologists keep blood sugar levels in check and conditions related to diabetes; nurses and dietitians are involved in behavior modification and providing patients with details on modifications. Because they are responsible for monitoring patients’ compliance with treatment schedules as well as any adverse effects of drug use, pharmacists have a vital role in the management of drugs.

Interprofessional Team Dynamics

For care results to be optimized there is a need to enhance interprofessional collaboration. Diabetes care in particular, often involves the members of the interprofessional teams working within the confines of PCNs because proximity fosters close professional relationships and face-to-face contact. These teams have face-to-face meetings often and have access to the client’s electronic health records (Vimalananda et al., 2023). Stakeholders are expected to have mutual respect and trust in the team members. For instance, pharmacists who are ASHP accredited and nurses with disease management specialty are often involved in important areas of patient information sharing as well as managing medication, thus releasing physicians to handle more complex work of diagnosis as well as decision making regarding treatment.

Ethical and Legal Considerations

Some of the legal and ethical factors that must be considered while developing solutions to facilitating Collaboration between practitioners are as follows: There is the need to ensure patient confidentiality and data integrity especially when multiple care professionals record or update a patient’s EHRS. Observing laws including HIPAA enhances confidence and secures the data of the patient (Wakefield et al., 2020). Therefore, it is essential to discuss some legal issues connected with delegation of work and the area of competence of different healthcare personnel. To mitigate risks, guidelines should be laid down and communicated often to the employees as well as making sure that all members of the team comprehend their roles as well as the laws governing the same. 

Data-Driven Outcomes in Care Coordination

Slide 9: Evaluation and improvement of the care coordination processes for the elderly diabetic population in Lakeside Height can be done by emphasizing the results extracted from the data. The first step is the collection of data that are the comparative values, the average concentration of HbA1c, the number of cases of hypoglycemia episodes, how often patients stick to the schedule of the prescriptions, the admission rate to hospitals for complications of diabetes (Northwood et al., 2023). Using contemporary health information systems such as MedConnect and CareLink, information concerning the efficiency of the existing procedures can be expanded. 

To determine whether the current approaches fit the proposed objectives, the collected data should be compared to certain standards, for instance, the American Diabetes Association standards. This means that continuative observation and evaluation of the results of care coordination need to be performed regularly, and using specific intervals. Conducting a post-secondary needs assessment for development and modification ought to be done every quarter (Hazlet et al., 2023). Some of the evaluations to be carried out include rechecking the HbA1c levels, monitoring the patient’s compliance with the medications prescribed, and reviewing the hospitalization status attributed to diabetes. Improvements, opportunities for improvement, or trends can also be better visualized when people make use of dashboards and analytics.

Recommendations to Sustain Outcomes in Care Coordination

Slide 10:  This can only be possible if the practices that enhance the improvement of the interventions continue to be practiced all the time so that good results are continually achieved and sustained in Lakeside Heights for aged diabetic patients. Of the practices that remain evident in today’s organizations, a key one worthy of mention is the continuous use of the data analytics model. The patient health status indicators, including HbA1c, medication taking and hospitalization should be performed regularly ideally at least quarterly (Northwood et al., 2023). For example, to gain insights regarding the nature and distinct trends of health data, it is possible to use modern HIS, as well as analytics tools to gain a fast understanding of problem areas. The role of the interprofessional team is to ensure that all involved persons are informed and can adapt accordingly to their circumstances, these evaluations ensure that all persons in the interprofessional team are well informed to deal with the situation. 

Recommendations to Sustain Outcomes

Slide 11: Medication compliance and HbA1c levels require quarterly evaluation hence the treatment of diabetes needs to factor these parametrics. This makes it possible to monitor the data continuously and also carry out assessments (Khatri et al., 2023).  Sophisticated health information systems are good for early identification of trends and possible areas for enhancing performance. Writing regular assessments with the interprofessional team ensures that there are improvements in the plan as well as involving the other members of the health care organization.

There is always a need for them to update their knowledge to incorporate new technologies and guidelines that are in the market (Khatri et al., 2023). There is also a need to put in practice processes that include diabetic self-management education classes conducted by pharmacists as well as chronic disease management nurses as a measure to ensure that they are regularly conducted. It also maintains involvement and trustful patient participation in their health care. The use of patient involvement in the development of the delivery of upcoming care and the plans for a patient as well as feedback help in improving the delivery of care that is given out.

Assessing Data Outcomes for Care Coordination Processes

The analysis of the data results is crucial since it helps one understand how well the care coordinating procedures are. Thus, the outcomes for monitoring and improving patient care include data-based outcomes, new and particular scores, and the time intervals for the subsequent evaluation (Vongsawad et al., 2022). For establishing starting points for such data as average HbA1c levels, frequency of hypoglycemic episodes, medicines’ compliance, and rates of admissions for diabetes complications, baseline data collection is needed. More information about the effectiveness of current processes is in the Health Information System which includes MedConnect and CareLink. It is necessary to deduce that gaps and areas in need of enhancement can be identified after comparing these data points with benchmarks, for instance, the American Diabetes Association (ADA) guidelines.

Conclusion

 Slide 12: The necessity of improving elderly diabetes client care integration in Lakeside Heights has been identified in this evaluation process. It is known that analysis of present moral and legal issues in treatment, revealing of evidence-based practice, and presentation of responsibilities of different teams and interested parties are important for the further enhancement of overall quality of care (Boatright et al., 2023).In this case, the care coordination procedures are of brief turnover and utmost patient orientation through the indication of such options as data outcomes, and short evaluation time frames. To maintain a healthy status and overcome the difficulties involved in managing those issues that elderly patients are confronted with, there will be a requirement to develop support and education that can be constantly provided to patients and health care providers or workers as well as ongoing assessment and adaptation of the approaches that have been taken.

References

Boatright, D., London, M., Soriano, A. J., Westervelt, M., Sanchez, S., Gonzalo, J. D., McDade, W., & Fancher, T. L. (2023). Strategies and best practices to improve diversity, equity, and inclusion among us in graduate medical education programs. JAMA Network Open, 6(2), e2255110. https://doi.org/10.1001/jamanetworkopen.2022.55110

Ford, J. H., 2nd, Gilson, A. M., Bryan, G., Augustine, C., Gassman, M., & Mott, D. A. (2021). Community pharmacy-based injectable naltrexone service delivery models and best practices. Research in Social & Administrative Pharmacy: RSAP, 17(7), 1332–1341. https://doi.org/10.1016/j.sapharm.2020.10.004

Hazelett, B. N., Paton, A., Majid, A., Johnson, M. M., Patel, N. M., Trujillo, D., Mateus, A. Y., Kornafeld, A., & Bussy, S. (2023). Coordination of care for expiratory central airway collapse: A structured process for a multifaceted disease. Chest, 163(1), 185–191. https://doi.org/10.1016/j.chest.2022.09.041

Khatri, R., Endalamaw, A., Erku, D., Wolka, E., Nigatu, F., Zewdie, A., & Assefa, Y. (2023). Continuity and care coordination of primary health care: a scoping review. BMC Health Services Research, 23(1), 750. https://doi.org/10.1186/s12913-023-09718-8

Karam, M., Chouinard, M. C., Couturier, Y., Vedel, I., & Hudon, C. (2023). Nursing care coordination in primary healthcare for patients with complex needs: A comparative case study. International Journal of Integrated Care, 23(1), 5. https://doi.org/10.5334/ijic.6729

Northwood, M., Shah, A. Q., Abeygunawardena, C., Garnett, A., & Schumacher, C. (2023). Care coordination of older adults with diabetes: A scoping review. Canadian Journal of Diabetes, 47(3), 272–286. https://doi.org/10.1016/j.jcjd.2022.11.004

Sahu, P. K., Dalcik, H., Dalcik, C., Gupta, M. M., Chattu, V. K., & Umakanthan, S. (2022). Best practices for effective implementation of online teaching and learning in medical and health professions education: during COVID-19 and beyond. AIMS Public Health, 9(2), 278–292. https://doi.org/10.3934/publichealth.2022019

Vongsawad, C. T., Bennion, A. H., Hollingsworth, S. P., Terry, K. N., Dobbs, C. E., Fronk, G. H., & Neilsen, T. B. (2022). Mentored student research: A case study evaluation of benefits and best practices. The Journal of the Acoustical Society of America, 152(4), 2054. https://doi.org/10.1121/10.0014348

Vimalananda, V. G., Meterko, M., Sitter, K. E., Qian, S., Wormwood, J. B., & Fincke, B. G. (2023). Patients’ experience of specialty care coordination: Survey development and validation. Journal of Patient-Centered Research and Reviews, 10(4), 219–230. https://doi.org/10.17294/2330-0698.2027

Walton, H., Simpson, A., Ramsay, A. I. G., Hunter, A., Jones, J., Ng, P. L., Beevers, K., Bloom, L., Kai, J., Kokocinska, M., Sutcliffe, A. G., Morris, S., & Fulop, N. J. (2022). Development of models of care coordination for rare conditions: a qualitative study. Orphanet Journal of Rare Diseases, 17(1), 49. https://doi.org/10.1186/s13023-022-02190-3

Wakefield, B. J., Lampman, M. A., Paez, M. B., & Stewart, G. L. (2020). Care management and care coordination within a patient-centered medical home. The Journal of Nursing Administration, 50(11), 565–570. https://doi.org/10.1097/NNA.0000000000000938