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Accountability for care delivery and self-care management.

Develop accountability for care delivery and self-care management.
Background
According to the Agency for Healthcare Research and Quality (AHRQ, 2020), “to provide effective self-management support (SMS), a team of clinicians and administrative staff need to coordinate closely with each other to provide care before, during, and after the patient visit. Successful teams are made up of clinical and administrative staff whose roles are planned in advance (para 7).”
Furthermore, the Joint Commission (Battersby et al., 2010) identified the following principles of patient self-care management:

  1. Clinical and health behavior assessments are brief and targeted

  2. Evidence-based information is used to guide patient-clinician discussions and shared decisions

  3. Clinicians and staff maintain a nonjudgmental approach to patients

  4. Patients and clinicians collaboratively prioritize & set goals & action steps

  5. Patients and clinicians collaborate, identify and solve goal-related problems

  6. Patients work on SMS with several members of the healthcare team; the commitment to SMS is practice-wide

  7. SMS interventions are delivered in a variety of formats (in person, by phone, online, via print materials)

  8. The focus is patient self-efficacy

  9. The healthcare team provides timely, active follow-up

  10. Case management is provided for selected patients

  11. Patients are linked to evidence-based community programs

  12. SMS is delivered and reinforced in numerous multifaceted interventions
    Assessment Instructions
    Considering what you have learned about APRN roles and the principles of patient self-care management previously, address the following points for this assessment in 4-5 pages not including the title or reference pages:

  13. Describe how an APRN would involve themselves in each of the following self-care management activities:
    o Gather clinical data before a visit.
    o Set agendas for patient visits.
    o Help patients set health goals.
    o Develop action plans for achieving goals.
    o Track health outcomes.
    o Refer patients to community programs.

  14. What APRN role(s) (i.e., certified nurse educator, nurse practitioner, nurse executive, clinical nurse specialist, certified nurse informaticist, advanced practice case manager, etc), would best fit each of the activities you chose?

  15. What intervention(s) would an APRN employ to support patient self-management for each activity you chose? For example, a nurse practitioner may use Motivational Interviewing techniques, a nurse executive may convene a task force, and a nurse educator may track outcomes and tailor educational offerings based on data. List and describe the interventions for each of the activities you chose. The AHRQ site below can support your search.

  16. What self-care management principles listed above support the interventions you describe?

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Sample Answer

 

 

 

Accountability for care delivery and self-care management is essential for ensuring high-quality, patient-centered care. Advanced practice registered nurses (APRNs) play a pivotal role in coordinating and facilitating these activities. By effectively engaging in self-care management activities, APRNs can empower patients to take control of their health and improve outcomes.

Full Answer Section

 

 

 

Overcoming Writer’s Block and Creating a Standout Dissertation

APRN Involvement in Self-Care Management Activities

  1. Gathering Clinical Data Before a Visit
  • Reviewing medical records: APRNs can review patients’ medical histories, previous diagnoses, and treatment plans to gather relevant clinical data.
  • Communicating with other healthcare providers: APRNs can coordinate with other members of the healthcare team, such as primary care physicians or specialists, to obtain additional information.
  • Utilizing electronic health records (EHRs): APRNs can leverage EHRs to access patient data efficiently and identify any potential concerns or areas for discussion.
  1. Setting Agendas for Patient Visits
  • Prioritizing patient needs: APRNs can work with patients to identify their most pressing concerns and prioritize the agenda for their visit.
  • Educating patients: APRNs can educate patients about the importance of self-care management and the benefits of active participation in their care.
  • Involving family members: APRNs can include family members or caregivers in the agenda-setting process to ensure that their perspectives are considered.
  1. Helping Patients Set Health Goals
  • Collaborating with patients: APRNs can work closely with patients to establish realistic and achievable health goals.
  • Providing guidance and support: APRNs can offer guidance and support to help patients stay motivated and focused on their goals.
  • Using motivational interviewing techniques: APRNs can employ motivational interviewing techniques to help patients identify their intrinsic motivation and develop a plan of action.
  1. Developing Action Plans for Achieving Goals
  • Breaking down goals: APRNs can help patients break down their goals into smaller, more manageable steps.
  • Identifying potential barriers: APRNs can help patients identify potential barriers to achieving their goals and develop strategies to overcome them.
  • Providing resources: APRNs can provide patients with resources, such as educational materials or community programs, to support their efforts.
  1. Tracking Health Outcomes
  • Monitoring progress: APRNs can track patients’ progress toward their goals using various tools, such as self-report questionnaires or electronic monitoring devices.
  • Providing feedback: APRNs can provide feedback to patients on their progress and make adjustments to their care plan as needed.
  • Celebrating successes: APRNs can celebrate patients’ achievements to reinforce positive behavior and maintain motivation.
  1. Referring Patients to Community Programs
  • Identifying appropriate resources: APRNs can identify community programs that can provide additional support and resources for patients.
  • Facilitating referrals: APRNs can assist patients in making referrals to community programs and ensuring a smooth transition of care.
  • Monitoring outcomes: APRNs can follow up with patients to assess the effectiveness of community programs and make adjustments as needed.

APRN Roles for Self-Care Management Activities

The most appropriate APRN role for each of these activities may vary depending on the specific context and the needs of the patient. However, some potential roles include:

  • Certified Nurse Educator: Ideal for providing education and support to patients in developing self-care management skills.
  • Nurse Practitioner: Can take a lead role in coordinating care, setting goals, and tracking health outcomes.
  • Nurse Executive: Can provide oversight and ensure that self-care management is a priority within the organization.
  • Clinical Nurse Specialist: Can offer specialized expertise in areas such as chronic disease management or geriatrics.
  • Certified Nurse Informaticist: Can help leverage technology to improve self-care management and data tracking.
  • Advanced Practice Case Manager: Can coordinate care for complex patients and ensure that they receive the necessary support and resources.

By effectively engaging in these self-care management activities, APRNs can empower patients to take control of their health and improve outcomes. Through collaboration, education, and support, APRNs can play a vital role in promoting patient self-efficacy and fostering a culture of accountability for care delivery.

 

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