NURS FPX 6614 Assessment 1 Defining a Gap in Practice


NURS FPX 6614 Assessment 1 Defining a Gap in Practice

NURS FPX 6614 Assessment 1 Defining a Gap in Practice


Capella university

NURS-FPX 6614 Structure and Process in Care Coordination

Prof. Name


Defining a Gap in Practice: Executive Summary

Effective care coordination is essential for improving health outcomes for elders with chronic obstructive pulmonary disease (COPD). Identifying the clinical priorities and matching them to evidence-based interventions that fit their specific needs are critical steps in overcoming the coordinated gaps in care. The executive summary of this paper provides the clinical priorities of the elders with COPD, which is the motivation for the PICOT question to bridge the gap and the discussion of services and resources available for care coordination (Pierucci et al., 2021).

Analyzing Clinical Priorities for Enhanced Care Coordination in Elders with COPD

Acknowledging the clinical priorities of COPD patients is essential because COPD impacts their quality of life and functional capabilities. This is because COPD is progressive and is associated with an increasing level of airflow limitation. The care coordination practices that are fragmented lead to inadequate management of the disease and unnecessary hospitalizations. A multidisciplinary care coordination plan that addresses the COPD-related needs of older adults and identifies the gaps in care can enhance care coordination, optimize disease management, and ultimately improve health outcomes. It recognizes the multi-directional character of COPD treatment and entails the integration of medical management, self-management education, and advanced care management (Agarwal et al., 2023).

PICOT Question to Address the Gap in Care Coordination

“In elders with COPD, how does implementing a multidisciplinary care coordination approach compared to standard care influence hospital readmission rates within six months?” Population: Elders with COPD

Intervention: Implementing a multidisciplinary care coordination approach

Comparison: Standard care

Outcome: Influence on hospital readmission rates

Timeframe: Within six months, at the organizational and regional levels

The multidisciplinary approach to care coordination for COPD patients is lacking, so the new system should address COPD complexity (Vachon et al., 2022).

Evaluation of Potential Services and Resources for Care Coordination

Various programs and services, including multidisciplinary teams, pulmonary rehabilitation, and telehealth technologies, support care coordination for elderly COPD patients. While these tools offer detailed assessments and personalized plans, challenges such as program absence and communication fragmentation exist. Overcoming these challenges requires collaboration among public health organizations, policymakers, and community stakeholders to ensure equitable access to care (Gaveikaite et al., 2020).

Assessment of Optimal Care Coordination Intervention

The interdisciplinary team-based model of care, grounded in evidence-based practices, emerges as the most successful approach to coordinating care for elders with COPD. This model integrates various healthcare professionals, including pulmonologists, primary care physicians, nurses, respiratory therapists, pharmacists, and social workers, to deliver comprehensive care tailored to each patient’s needs (Brooks & Levy-Milne, 2022). Implementation involves establishing care coordination teams within healthcare organizations, led by coordinators or case managers, to standardize protocols and leverage technology for improved communication while prioritizing patient preferences and goals (Madawala et al., 2022).

Summary of Selected Nursing Diagnosis for Collaborative Care

The nursing diagnosis for COPD in elders highlights the compromised states of gas exchange, airway clearance, and activity tolerance, demanding a collaborative approach. This strategy aims at integrating several disciplines, including pulmonary rehabilitation, self-management, and physical therapy, to improve the quality of life. The types of interventions include medication adjustment, pulmonary rehabilitation referrals, and educating the patients (Siddiq et al., 2020). Enabling elders through their own designed action programs and remote surveillance will be a significant factor in promoting self-management. Alongside, exercise programs based on structure as well as occupational therapy restrict activity intolerance and ensure independence (Bell et al., 2020).

Planning the Intervention and Expected Outcomes in Care Coordination

The care coordination intervention for elderly COPD patients prioritizes meeting established standards while focusing on patient needs and outcomes. It includes essential elements such as needs assessment, individual care planning, evidence-based interventions, and continuous assessment. Expected outcomes encompass reduced hospital readmissions, improved disease management, and increased patient satisfaction, ultimately aiming to enhance health and overall satisfaction. Establishing transparent communication protocols, offering individualized self-care support, and fostering a culture of continuous improvement is crucial for successful implementation (Arnold et al., 2020).


Addressing the care coordination gap for elders with COPD necessitates a holistic and collaborative approach. By grasping their clinical priorities and utilizing evidence-based interventions, healthcare providers can enhance care coordination, leading to better health outcomes and improved quality of life. Collaboration among various stakeholders is crucial for overcoming barriers and ensuring the successful implementation of care coordination strategies. Through this, ongoing improvements in outcomes can be achieved.


Agarwal, A. K., Raja, A., & Brown, B. D. (2023, August 7). Chronic obstructive pulmonary disease (COPD). National Library of Medicine; StatPearls Publishing.

Arnold, M. T., Dolezal, B. A., & Cooper, C. B. (2020). Pulmonary rehabilitation for chronic obstructive pulmonary disease: Highly effective but often overlooked. Tuberculosis and Respiratory Diseases83(4), 257–267.

Bell, S. C., Mall, M. A., Gutierrez, H., Macek, M., Madge, S., Davies, J. C., Burgel, P.-R., Tullis, E., Castaños, C., Castellani, C., Byrnes, C. A., Cathcart, F., Chotirmall, S. H., Cosgriff, R., Eichler, I., Fajac, I., Goss, C. H., Drevinek, P., Farrell, P. M., & Gravelle, A. M. (2020). The future of cystic fibrosis care: A global perspective. The Lancet Respiratory Medicine8(1), 65–124.

Brooks, K., & Levy-Milne, R. (2022). Educating frontline health workers to support evidence-based management and treatment for chronic obstructive pulmonary disease patients: A literature review. Canadian Journal of Respiratory Therapy58, 127–135.

Gaveikaite, V., Grundstrom, C., Winter, S., Schonenberg, H., Isomursu, M., Chouvarda, I., & Maglaveras, N. (2020). Challenges and opportunities for telehealth in the management of chronic obstructive pulmonary disease: A qualitative case study in Greece. BioMedCentral MC Medical Informatics and Decision Making20(1).

NURS FPX 6614 Assessment 1 Defining a Gap in Practice

Liu, K., Tronstad, O., Flaws, D., Churchill, L., Alice, Nakamura, K., & Fraser, J. F. (2024). From bedside to recovery: Exercise therapy for prevention of post-intensive care syndrome. Journal of Intensive Care12(1).

Madawala, S., Osadnik, C. R., Warren, N., Kasiviswanathan, K., & Barton, C. (2022). Healthcare experiences of adults with Chronic Obstructive Pulmonary Disease (COPD) across community care settings: A meta-ethnography. ERJ Open Research9(1), 00581-2022.

Pierucci, P., Santomasi, C., Ambrosino, N., Portacci, A., Diaferia, F., Hansen, K., Odemyr, M., Jones, S., & Carpagnano, G. E. (2021). The patient’s treatment burden is related to care coordination in the field of respiratory diseases. Breathe17(1), 210006.

Siddiq, M. A. B., Rathore, F. A., Clegg, D., & Rasker, J. J. (2020). Pulmonary rehabilitation in COVID-19 patients: A scoping review of current practice and its application during the pandemic. Turkish Journal of Physical Medicine and Rehabilitation66(4), 480–494.

Vachon, B., Giasson, G., Gaboury, I., Gaid, D., Noël De Tilly, V., Houle, L., Bourbeau, J., & Pomey, M.-P. (2022). Challenges and strategies for improving COPD primary care services in Quebec: Results of the experience of the COMPAS+ quality improvement collaborative. International Journal of Chronic Obstructive Pulmonary DiseaseVolume 17(1), 259–272.

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