Accountability for Care Delivery

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:

1. Describe how an APRN would involve themselves in each of the following self-care management activities:
   • Gather clinical data before a visit.
   • Set agendas for patient visits.
   • Help patients set health goals.
   • Develop action plans for achieving goals.
   • Track health outcomes.
   • Refer patients to community programs.
2. 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?
3. 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.
4. What self-care management principles listed above support the interventions you describe?

For this assessment, you will use the template provided in the Course Resources.

The assessment must demonstrate proper APA formatting as directed in the APA Publication Manual, 7th edition, including a title page and reference list, with properly formatted citations in the body of the assessment. You are encouraged to consult the Academic Success Center before submitting your work.

To view the grading rubric for this assessment, please visit the Grading Rubrics section of the Course Resources.

Assessment Requirements:

Before finalizing your work, you should:

• be sure to read the assessment description carefully (as displayed above);
• consult the grading rubric (under the Course Resources) to make sure you have included everything necessary, and
• utilize spelling and grammar checks to minimize errors.

Your writing assessment should:

• follow the conventions of Standard English (correct grammar, punctuation, etc.);
• be well-ordered, logical, and unified, as well as original and insightful;
• display superior content, organization, style, and mechanics; and
• use APA 7th edition format.

References

Agency for Healthcare Research Quality. (2020). Self-management support. https://www.ahrq.gov/ncepcr/tools/self-mgmt/self.html

Battersby, M., Von Korff, M., Schaefer, J., Davis, C., Ludman, E., Greene, S. M., Parkerton, M., & Wagner, E. H. (2010). Twelve evidence-based principles for implementing self-management support in primary care. Joint Commission Journal of Quality and Patient Safety, 36(12), 561–70. https://www.sciencedirect.com/science/article/abs/pii/S1553725010360843?via%3Dihub