Care Coordination Presentation to Colleagues

Hello and welcome to this session on the fundamental principles of care coordination in nursing practice. My name is Marjacha Mbah Christina. In this presentation, I will explore care coordination as practiced in contemporary nursing and highlight ethical concerns, policy issues, and the identification and deployment of community resources in nursing care coordination. Many people, including nurses, imagine that care coordination is a vehicle with many cogs working together to provide collaborative patient-centered care. While this is true, care coordination as practiced is subject to many legal, ethical, administrative, and other checks and balances aimed at maintaining suitability and ensuring that the rights of patients are upheld.

Effective Strategies for Collaborating with Patients and Their Families

According to an article by Harkness in 2020, nursing officers must be ready to engage patients and their families in care coordination. Effective collaborative strategies are mandatory in patient- and family-centered high-quality care delivery. An article by Goodridge et al. in 2018 described different strategies to engage patients and their families. They include leadership and accountability, teamwork and communication, trust, negotiation, and transparency. A strategy under leadership and accountability aspect is the need for nurses and patients to agree on the goals of care and the roles of each party. The strategy ensures that all the involved parties are accountable for their goal achievement. Drug-use counseling is done under the concept of teamwork and effective communication. Goodridge et al. in 2018 reported that patients and their families are included as members of the team and accurately, quickly, and pertinently about their health and care. Information shared may include the drug used, the rationale for use, possible adverse drug reactions, and warnings.

Aspects of Change Management Directly Affecting Elements of the Patient Experience

The high volume and rapid changes in the healthcare sector, such as care coordination, necessitate change management. Change management is a critical step that determines the success or failure of healthcare initiatives. According to an article by Harrison et al. in 2021, incorporating the components of the main change management models in the design, planning, and strategic implementation of change is fundamental. Change management involves six components: leadership alignment, engagement of stakeholders, effective communication, determining readiness and impact, training, and organizational transformations. Fostering communications and collaborations during these steps ensures that nurses effectively advocate for patients, educate and engage them, and evaluate the impacts of change. For that reason, transition management may have positive implications for patient safety. Harkness, in 2020, reported that effective communication and collaboration during transitions reduce acute exacerbations of chronic diseases and increase readmission rates.

The Rationale for Coordinated Care Plans Based on Ethical Decision Making

Nurses need to influence patient care based on their ethical obligations. Ethical principles, such as beneficence, non-maleficence, autonomy, and justice, give power to nurses to be involved in ethical decision-making regarding patient care. The ethical decision requires nurses to consider the conflict between competing values, usually personal, professional, or organizational, during care delivery. Collaboration between healthcare professionals in care coordination is founded on effective communication. Accordingly, integrating electronic health communication in coordinated care has supported information sharing in coordinated care. Professional ethics should guide the dissemination and disclosure of this patient-protected information. Evidence-based care is founded on making informed care decisions through the use of information systems in decision support. Nurses who understand their ethical obligations will use this knowledge to influence their practice and that of others. Accordingly, this best practice of care coordination implies that any interventions will be based on the needs of the individual patient in their realities.

Moreover, the concept of shared decision-making draws from deontology, whereby nurses and other healthcare team members follow the rules set by regulatory policies to arrive at treatment decisions. Patients should be treated holistically to give them the highest quality of care. However, consequences of this ethical approach may rise. The patient-centered approach to care coordination assumes that patients want and can be included in their care process. Further, patients may assume that all information is medically relevant, thus sharing information that they would otherwise prefer not to. The consequence of this is a potential ethical conflict, an infringement on the patient’s privacy. Understanding this possible conflict helps ensure that decision-making is appropriately informed and shared while still upholding the patient’s needs and interests (Hansson & Fröding, 2020).

Potential Impacts of Policy on Patient Outcomes and Patient Experiences

The healthcare sector has experienced several legislative and policy changes that have directly impacted patient clinical outcomes and their experiences. The Affordable Care Act of 2010 increased health insurance coverage by about 20 million people. It expanded public funding of Medicaid for adults and made it possible for individuals to purchase private insurance. Through the Medicaid and Medicare programs, many vulnerable people had access to insurance, a critical factor in determining coordination and continuity of care. The result is improved access to high-quality medical care, improved clinical outcomes, and improved uptake of preventive and outpatient medical services (Kominski et al., 2017). Through the Hospital Readmissions Reduction Program, Medicare improved patient safety and enhanced quality of care through performance-based reimbursement strategies. Another policy that has improved patient safety includes the Patient Safety and Quality Improvement Act of 2005.

The Health Insurance Portability and Accountability Act of 1996 significantly affected patient outcomes and overall experience. It protected patients with preexisting conditions from being excluded by health insurers. Additionally, it improved administrative functions and efficacy in the healthcare industry and assured the protection of patient identifying information. Patients were assured of privacy and confidentiality. These policies have had significant positive implications on clinical outcomes and patient experience.

Raising Awareness of the Role of Nurses in the Coordination and Continuum of Care

Nurses have a critical role in care coordination, especially for people with complex societal and healthcare needs. They are involved in identifying patients requiring comprehensive interventions and inviting them to receive care. Nurses also assess their needs and goals, develop individualized care plans, educate the patients, directly provide care, and undertake patient monitoring and follow-up. Through these interventions, they establish continuity of care by developing personal and meaningful therapeutic relationships founded on mutual trust. In palliative care, nurses identify advance directives if present and ensure that the patient’s rights and preferences are adhered to. Finally, as chief patient advocates, nurses support patient engagement and empowerment through collaborative undertakings with all healthcare system stakeholders (Karam et al., 2021). These roles are the center of care coordination undertakings, and nurses are uniquely placed to lead. Nurses can classify the roles and responsibilities of professionals in multidisciplinary teams, foster relationships, and ensure care is consistent with policy and legal provisions.

References

Goodridge, D., Henry, C., Watson, E., McDonald, M., New, L., Harrison, E. L., Scharf, M., Penz, E., Campbell, S., & Rotter, T. (2018). Structured approaches to promote patient and family engagement in treatment in acute care hospital settings: protocol for a systematic scoping review. Systematic Reviews, 7(1). https://doi.org/10.1186/S13643-018-0694-9

Hansson, S. O., & Fröding, B. (2020). Ethical conflicts in patient-centered care: Https://Doi.Org/10.1177/1477750920962356, 16(2), 55–66. https://doi.org/10.1177/1477750920962356

Harkness, T. L. (2020). Effective care coordination and transition management for older adults. https://doi.org/10.1097/01.NME.0000694184.27758.b9

Harrison, R., Fischer, S., Walpola, R. L., Chauhan, A., Babalola, T., Mears, S., & Le-Dao, H. (2021). Where Do Models for Change Management, Improvement and Implementation Meet? A Systematic Review of the Applications of Change Management Models in Healthcare. Journal of Healthcare Leadership, 13, 85. https://doi.org/10.2147/JHL.S289176

Karam, M., Chouinard, M. C., Poitras, M. E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, C. (2021). Nursing Care Coordination for Patients with Complex Needs in Primary Healthcare: A Scoping Review. International Journal of Integrated Care, 21(1). https://doi.org/10.5334/IJIC.5518

Kominski, G. F., Nonzee, N. J., & Sorensen, A. (2017). The Affordable Care Act’s Impacts on Access to Insurance and Health Care for Low-Income Populations. Annual Review of Public Health, 38, 489. https://doi.org/10.1146/ANNUREV-PUBLHEALTH-031816-044555

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