The purpose of this assignment is to analyze the role of managed care organizations within health care and risk management programs.

Reflect on and evaluate the role that the managed care organization (MCO) plays in today’s health care environment by developing a 250‐500-word response that addresses the following:

1. What is a health care organization’s administrative role in executing risk management policies and ensuring compliance with managed care organization (MCO) standards?
2. What value do the regulatory statutes of a typical MCO provide to a health care organization? Consider how strategies pertaining to policies such as conflict resolution and risk management affect patients as well as employees and employers.
3. What MCO responsibilities relevant to the Patient Protection and Affordable Care Act (ACA) and Center for Medicare and Medicaid Services (CMS) focus on fraud, waste, and abuse laws?

In addition to your textbook, you are required to support your analysis with a minimum of two peer‐reviewed references.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance.

Write a 3-4 page evidence-based health care delivery plan for one component of a heart failure clinic.

 

Instructions

Deliverable: Develop an evidence-based plan for health care delivery.

Scenario:

The hospital where you work has an issue with increased readmissions within 30 days of discharge. After examining the core measures, it was found that heart failure was the most common core measure disease process experiencing the highest rate of readmissions. The leadership team has given your team the charge of developing a nurse-run outpatient heart failure clinic. The purpose of this clinic is to ensure that discharge education is presented to the patient in an orderly, consistent manner and complies with evidence-based practice protocols. Since these patients may be discharged from a variety of areas in the facility, having the heart failure clinic staff take ownership of the process will improve both consistency and compliance. There are cardiologists that interact with the staff and patients, but the day-to-day operations of the clinic are designed and supported by the nurses as they interact with appropriate members of the other health care team disciplines promoting the best care for the heart failure patients.

As a member of the nurse team, you have been asked to develop one component of the clinic.

The hospital leadership established these objectives for the clinic services:

• Evaluate and maximize proper medication therapy.
• Conduct regular diet, exercise, and stress management classes for the patients.
• Monitor physiological indicators for the patients (lab work, weights, vital signs, ECGs).
• Provide a case management system for patients in the program post-discharge.

The overall goals for the heart failure clinic are to:

• Enroll greater than 90 percent of the patients with a primary or secondary diagnosis of HF prior to discharge.
• Facilitate discharge planning to achieve 100 percent compliance with patient education prior to discharge (discharge planning).
• Decrease readmission rates in this population by 5 percent over the next year.

The leadership team has asked you to provide them with an evidence-based plan for one of the components of the clinic. You may use any combination of documents (for example, a spreadsheet or a table) in addition to explanatory information to convey information clearly and succinctly.

Develop one: an Orientation Course Plan, a Discharge Education Plan, or a Care Coordination Plan.

An Orientation Course Plan:

• Develop an evidence-based plan for health care delivery.
• Include a comprehensive schedule of topics, objectives, key points, and patient resources for the orientation course.
  • What are the components of an evidence-based education plan?
  • How will you know that patients will understand what to do?
  • What modalities will you use to deliver information?
  • How will you adapt the plan to meet the needs of patients from diverse cultural and language backgrounds?
  • Identify specialized and supplementary material needs.
• Apply professional and legal standards in support of a care plan.
  • Explain the alignment to the most recent Heart Failure Guidelines and specific professional standards.
  • Describe the accountability tools and procedures used to measure effectiveness.
  • How will you know if the patient education plan is successful?
  • What are the indicators of success or effectiveness?

A Discharge Education Plan:

• Develop an evidence-based plan for health care delivery.
  • Develop a discharge plan with objectives and resources, and tools for patients to monitor their progress.
  • How will you know that patients understand what to do?
  • What modalities will you use to deliver information?
  • How will you adapt the plan to meet the needs of patients from diverse cultural and language backgrounds?
• Apply professional and legal standards in support of a care plan.
  • Explain the alignment to the most recent Heart Failure Guidelines and specific professional standards.
  • Describe accountability tools and procedures used to measure effectiveness.
  • How will you know if the discharge plan is successful?
  • What are the indicators of success or effectiveness?

Care Coordination Plan:

• Develop an evidence-based plan for health care delivery.
  • Develop a procedure for coordinating services.
    • Consider the needs of “outliers.” For example, someone with lung disease may need extra resources.
    • Who should be on the team?
    • When would the team be activated?
    • How would it be activated?
    • What is the time frame required to coordinate services?
    • How would the intervention plan be monitored for effectiveness?
• Apply professional standards in support of a care plan.
  • Explain the alignment to the most recent heart failure guidelines and specific professional standards.
  • Describe accountability tools and procedures used to measure effectiveness.
    • How will you know if the care coordination plan is successful?
    • What are the indicators of success or effectiveness?
    • How will information be collected or communicated?

Additional Requirements

• Written communication: Written communication should be free of errors that detract from the overall message.
• APA formatting: Resources and in-text citations should be formatted according to current APA style and formatting.
• Length: The report should be 3-4 pages in content length, double-spaced.
• Font and font size: Times New Roman, 12 point.
• Number of resources: Support your plan with a minimum of three peer-reviewed resources, in addition to professional standards.

In the media introduction to this module, it was suggested that you as a nurse have an important role in the Systems Development Life Cycle (SDLC). With a focus on patient care and outcomes, nurses may not always see themselves as contributors to the development of new systems. However, as you may have observed in your own experience, exclusion of nurse contributions when implementing systems can have dire consequences.

In this Discussion, you will consider the role you might play in systems development and the ramifications of not being an active participant in systems development.

To Prepare:

Review the steps of the Systems Development Life Cycle (SDLC) as presented in the Resources.
Reflect on your own healthcare organization and consider any steps your healthcare organization goes through when purchasing and implementing a new health information technology system.
Consider what a nurse might contribute to decisions made at each stage of the SDLC when planning for new health information technology.
Post a description of what you believe to be the consequences of a healthcare organization not involving nurses in each stage of the SDLC when purchasing and implementing a new health information technology system. Provide specific examples of potential issues at each stage of the SDLC and explain how the inclusion of nurses may help address these issues. Then, explain whether you had any input in the selection and planning of new health information technology systems in your nursing practice or healthcare organization and explain potential impacts of being included or not in the decision-making process. Be specific and provide examples.

APA 3 to 5 reference less than 5 years

In collaboration with your approved course mentor, you will identify a specific evidence-based practice proposal topic for the capstone project. Consider the clinical environment in which you are currently working or have recently worked. The capstone project topic can be a clinical practice problem, an organizational issue, a quality improvement suggestion, a leadership initiative, or an educational need appropriate to your area of interest as well as your practice immersion (practicum) setting. Examples of the integration of community health, leadership, and an EBP can be found on the “Educational and Community-Based Programs” page of the Healthy People 2020 website.

Write a 500-750 word description of your proposed capstone project topic. Make sure to include the following:

The problem, issue, suggestion, initiative, or educational need that will be the focus of the project

The setting or context in which the problem, issue, suggestion, initiative, or educational need can be observed.

A description providing a high level of detail regarding the problem, issue, suggestion, initiative, or educational need.

Impact of the problem, issue, suggestion, initiative, or educational need on the work environment, the quality of care provided by staff, and patient outcomes.

Significance of the problem, issue, suggestion, initiative, or educational need and its implications to nursing.

A proposed solution to the identified project topic

You are required to retrieve and assess a minimum of 8 peer-reviewed articles. Plan your time accordingly to complete this assignment.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.

The Assignment

Examine Case Study: A Young Caucasian Girl With ADHD You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

• Decision #1
  • Which decision did you select?
  • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
• Decision #2
  • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  • Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
• Decision #3
  • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

Also include how ethical considerations might impact your treatment plan and communication with clients.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.