Analyze the application of technology and professional standards related to your health process issue (lack of continuity of care) at your practicum site (home health nursing) in a 4–6 page paper. Ba
Continuity of Care Challenges in Home Health Nursing
Continuity of Care Challenges in Home Health Nursing
Introduction
A patient’s recovery relies heavily on continuity of care during their hospital-to-home healthcare transition. This is because it determines their access to prompt medical treatments. The clinical rotations at my practicum site, a home health nursing agency, have shown an insufficient quantity of continuity of care for its patients. The consistent rotating nature of staffing has produced two significant consequences: healthcare professionals are increasingly likely to miss essential patient changes which subsequently prevents necessary interventions, resulting in readmissions with longer hospital stays for these patients. This paper examines the process issue, evaluating its impact on patient outcomes and organizational performance, as well as the strategic clinical and operational choices made to mitigate it.
Description of the Practicum Site
This home health agency operates from a location in Oklahoma, where nurses deliver medical care directly to patients residing throughout diverse regions of the community. The healthcare institution often treats patients after orthopedic surgery, those with congestive heart failure, individuals with wounds, and clients facing cancer and chronic illnesses. The agency operates with a workforce of 600 full-time employees at office and field levels. They encounter challenges resulting from a high turnover rate within a military community, where regular nurse transitions prevent sustained nurse-patient continuity. The nurse rotation policy aims to balance the workload but ultimately disrupts important patient-health monitoring continuity, leading to impaired response abilities to changes in patient health. (Heidenreich et al. 2013).
Clinical and Operational Decisions
The agency's focus is on creating customized care protocols for patients. The clinical team makes its own decisions regarding patients' orders, and then the implementation of scheduling decisions and chart review processes comprise operational decisions within the entity. The nursing staff has limited decision-making power in policy choices, while higher-level administrative heads primarily determine the staff rotation guidelines. Week-to-week rotating protocols restrict nursing staff from achieving a comprehensive understanding of patient profiles, making it difficult for them to notice minor changes in patient health. This unstable level of care increases the likelihood of hospital readmissions.
The problem worsens because nurses who rotate do not communicate directly with one another. Patient records in electronic health records (EHRs) often lack reliability due to incomplete and inconsistent documentation in their processes. Without accurately understanding a patient's fundamental medical state, nurses can fail to detect the initial indications of worsening health, which can result in missed opportunities for immediate medical intervention. (Russell et al. 2011). Patients having to recount their treatment plans to multiple caregivers frequently leads many patients and their families to feel distrust toward a home health agency. A formal handoff system based on nurse-to-nurse verbal reporting at shift changes will boost the continuity of patient care.
Analysis of the Process Issue
The most significant process problem concerns patient care continuity, which is disrupted due to inconsistent and ever-changing nursing staff. Patient health assessment crucially depends on regular contact between nurses and patients, who must detect significant, although subtle, changes in condition. Regular patient care by distinct nurses during each workweek can lead to missed critical signs, which delays vital treatments and causes more patients to return to the hospital. The insufficient method by which nurses review patient records before and after shifts creates additional challenges to achieving better patient care. The failure to perform an extensive chart presents patient data being insufficiently passed to other caregivers, thus increasing the potential for adverse health events. Research findings now recognize that enhanced continuity in home health care results in superior patient health results together with decreased hospital admission rates. (Tiso et al., 2023). Healthcare organizations face substantial economic impacts because readmissions drive up both care delivery expenses and financial penalties used to determine patient readmission rates.
The Effect on Medical Quality Results and Safety Measures
The current approach has significant effects on both the quality of care and patient safety, as well as healthcare expenses. Inconsistent care delivery methods result in fragmented clinical data exchange and lower patient service quality ratings—hospital patients often lack caregivers' experience in forming trust relationships for medical treatment. Patients experience higher safety risks because of sporadic monitoring because medication mistakes and delayed critical condition responses become more frequent, especially among patients with ongoing health conditions or surgical recovery requirements. The financial costs associated with hospital readmissions are high. (Caballero, 2024).
Hospital readmissions at a higher rate create sustained negative impacts on both organizations serving patients and their patient population. Home health agencies experience penalties from insurance providers and reduced payment amounts through Medicare and other providers due to multiple hospital admissions by their patients. The cost of hospital stays increases healthcare expenses for both organizational facilities and individual patients who need to pay larger medical bills and spend additional time recovering. A patient-centered approach notes that the lack of care continuity leads to substandard health outcomes. This is because patients experience slower rehabilitation and higher risks of complications. Presently, addressing nurse-patient continuity alongside communication strategies would enable better care quality and safety, as well as cost reduction benefits.
Recommendations for Process Improvement
Multiple integrated strategies must be employed to address the current process challenges. Complete patient assessments must occur during every shift transition through the establishment of advanced protocols for chart reviews. Standardized checklists for chart reviews will support shift-to-shift data transfers, along with reducing errors in documentation between shifts. An evaluation process of staffing structures must be followed to determine potential modifications. The patient experience benefits from longer nurse assignments and designated nurse duties for high-risk patients, which leads to stronger patient-staff interactions and faster responses. (Kinard et al. 2024). Immediate system updates, along with detailed communication notes generated by modern electronic health record (EHR) systems, help reduce communication gaps between nurses working weekly shifts. The combination of ongoing training regarding both best patient care methods and efficient chart assessment supports practitioners in adopting new changes. The newly implemented processes require regular evaluations to validate their effectiveness in managing the issue and measuring their impact on patient outcomes.
Conclusion
Home health care needs continuous patient care to achieve success while handling complex medical cases. The weekly nurse staff replacement system without effective information transfer systems harms patient safety, weakens care quality, and increases healthcare costs. This research examined the impact of discontinuity on patient outcomes, as well as hospital readmission costs and operational difficulties that exacerbate these results. The improved communication systems enable home health agencies to deliver better patient care.
References
Caballero, I. (2024). Evaluation of Multidisciplinary Clinician Documentation in a Home Health Agency (Doctoral dissertation, Azusa Pacific University).
Heidenreich, P. A., Albert, N. M., Allen, L. A., Bluemke, D. A., Butler, J., Fonarow, G. C., ... & Trogdon, J. G. (2013). Forecasting the Impact of Heart Failure in the United States: A Policy Statement from the American Heart Association. Circulation: Heart Failure, 6(3), 606-619.
Kinard, T., Brennan-Cook, J., Johnson, S., Long, A., Yeatts, J., & Halpern, D. (2024). Effective Care Transitions: Reducing Readmissions to Enhance Patient Care and Outcomes. Professional Case Management, 29(2), 54-62.
Russell, D., Rosati, R. J., Rosenfeld, P., & Marren, J. M. (2011). Continuity in Home Health Care: Is Consistency in Nursing Personnel Associated with Better Patient Outcomes? Journal for Healthcare Quality, 33(6), 33-39.
Tiso, A., Cháfer-Vilaplana, J., Torrego Ellacuría, M., Morales Contreras, M. F., & Verbano, C. (2023). Lean and safety management: a project to improve the continuity of care for chronic patients.
