PLEASE RESPOND TO THE BELOW POST:
INSTRUCTIONS:
All responses should be a minimum of 300 words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required (within 5 years).
POST
The research question and PICOT for this project are a result of this provider’s experience discussing live hospice discharge with the nurse case managers of the hospice organization. The regulations placed on hospice admission and discharge are enforced through the Centers for Medicare and Medicaid. These regulations cause distress for caregivers and nurses alike who are committed to the care of their patients. Clayton et al. (2022) explain that unanticipated or undesired live discharge is distressing to patients, families, and hospice staff. Caregivers often express concerns regarding future needs if symptoms increase and how they will communicate their needs to a healthcare provider.
The discharge process along with caregiver to healthcare provider communication after live hospice discharge is an area that has been identified by this DNP student as a potential opportunity for improvement in the discharge plan. As noted by Mc Curry and Hunter Revell (2015) due to changing health status of the care recipient, caregivers often require ongoing communication with members of the healthcare team and reinforcement of education provided. As care recipients’ health needs change, family caregivers will need assistance to modify the plans of care. This is where the SDDM framework can provide organization and assist the caregiver in providing clear information to the provider that can allow for targeted, personal care.
This DNP project aims to address the concerns of caregiver healthcare provider communication after discharge by evaluating a common language communication tool called the Sieben’s Notebook for Well-Being and Healthcare. This communication tool is based on the Domain Management Model, a systematic classification of patients’ clinical problems and their management (Sieben’s, 2002). Sieben’s (2002) asserts the importance of the biopsychosocial model in patient centered care and explains that the Domain Management Model provides a well-organized and easy to understand framework for patients, informal and formal caregivers, and healthcare providers. The model covers four integral areas or domains of care management including the patient’s medical/surgical history and issues, mental status, emotions and coping, physical function and living environment (Sieben’s, 2005).
According to Sieben’s (2023) the framework makes person/patient-centered treatment planning and care delivery easier among teams and over time across inpatient and outpatient settings.