Effective Care Coordination – Ensuring Comprehensive Patient-Centered Care

Effective Care Coordination – Ensuring Comprehensive Patient-Centered Care

Hello and welcome to this lesson in which we focus on the care coordination process and the continuum of care. My name is AON. I am very pleased to be your mentor and colleague as you continue to improve your nursing skills. Today, I will help you to best understand fundamental principles of care coordination across the continuum of care, including the utilization of community resources, ethical and policy issues that affect the coordination of care, and the aspects of change management that are directly linked to patient experience and the provision of high-quality and patient-centered care. In this video, I will also touch on the rationale for coordinated care plans based on ethical decision-making and provide specific examples of policy provisions that may affect how your coordinated care plan achieves its intended outcomes and patient experiences. The overall aim of this video is to help you fully understand and appreciate your role in the coordination and continuum of care and why your role is vital to achieving the best care outcomes and patient experiences.

First, let me introduce to you some strategies that are effective for collaborating with patients and their families to achieve desired health outcomes. As a nurse, one thing you must be aware of, whether you are at the beginning of your career or have been practicing for a while, being a nurse means that you will always collaborate with other health professionals, families, and other healthcare service providers to ensure the care provided to patients as argued by Edgman-Levitan & Schoenbaum (2021); care that is comprehensive, of the highest quality, and centered around the needs, values, preferences of the patient. The fact is that you will always be the main coordinator of the care provided to the patients. Therefore, you will need to understand a few strategies that will help you best collaborate with your patients and their families during the coordination of care.

The first and most effective strategy is the use of culturally sensitive communication. As Handtke et al. (2019) note, as the patient population is growing culturally and linguistically diverse, language barriers have become common restrictions in the access and provision of care, creating the need for cultural competence in healthcare practice. The use of culturally sensitive communication, as Brooks et al. (2019) argue, during the interactions between clinicians, patients, and their families improves how patients and their families understand the situation, cooperate, and get engaged during the provision of care. Besides the use of culturally competent communication, it is also important to educate the patients on their condition and the medication, which can help improve how much they get involved in the development of their care plan. As a nurse, you will need to individualize the education protocol to the specific patient needs, condition, and medications with a focus on why it is necessary to use the medication, how to best take the medication, side effects, and how to observe the side effects and reporting protocols for any exacerbations. Tobiano et al. (2019) point out that patient education, especially medication education, significantly improves patient engagement during admission and discharge, leading to greater adherence and reduced risk of errors and readmissions.

One thing you will need to understand is that the coordination of care across the care continuum involves a lot of changes. This is why you, as a coordinator of care, must understand the aspects of change management that directly impact patient experience and the provision of high-quality and patient-centered care. For instance, leadership. The nature of the leadership during care coordination affects the effectiveness of the care team and collaboration with the patient and their families. You must ensure that the leadership of the entire team remains strong and focused on the goals of the care plan. Another aspect of change management that is essential to a positive patient experience and the provision of high-quality patient-centered care is the level of engagement of the patients and members of the care coordination team. Employ strategies that promote high levels of engagement, such as the use of culturally sensitive communication, as we identified earlier in this video. It is also essential to educate the patient and their families, as well as employ a system for collecting and providing feedback as the care coordination plan is being implemented.

Now, let me show you why it is important to anchor all your coordinated care plans on ethically made decisions. Ethical decision-making means basing all decisions of the coordinated care plan on ethical principles. First, basing all decisions on ethical principles can improve the relationship between the care provider and the patient, as well as guarantee the quality of care provided. For instance, Molina‐mula & Gallo‐estrada (2020) in their study report that there is a direct interaction between nurses and their patients, and the development of quality care plans and patient autonomy are all considered in the making of any care decisions. This is to say that considering patient autonomy and having a good relationship between patients and their care providers can lead to the provision of high-quality care. However, to guarantee autonomy during the coordination of care, the nurse must sufficiently educate the patient on the various specifics of their health condition, medication, and any other aspects of care in order to make informed decisions. Additionally, it is important to note that ethical decision-making in the development of a coordinated care plan can ensure a more patient-centered care plan, as considerations are based on how the care plan best benefits the patient and how less likely it is to harm the patient in any way including physically, mentally, and financially.

Before I wrap up, it is important to understand that all care coordination plans must align with the existing policy regulations. Although most of these regulations can be considered to be general for aspects of healthcare settings, there are specific regulation provisions that can impact the coordination of care, outcomes, and patient experience. There are several policy provisions; however, let me point at one specific policy and its provisions that you must consider in all care coordination plans across the continuum of care: the Health Insurance Portability and Accountability Act (HIPAA) and specifically the “Privacy Rule.” The HIPAA, under the Privacy Rule, defines the rules of patient health information and covered entities and sets standards for data sharing, protection of all PHI, and ownership of PHI. Since control of health information is given to patients who decide who has access to such information, it can be concluded that since some patients are worried about their privacy and confidence in their health information, they may withhold some information that may affect care coordination. For instance, Ivanova et al. (2020) note that patients withhold information and may experience inefficiencies in care coordination and quality of care due to missing health information.

In conclusion,

Care coordination is a critical role for nurses in practice as it central to the achievement of optimum patient care outcomes and experiences. Regardless of the situation, you as a nurse are expected to adhere to the ethical principles in all decisions made toward the development of coordinated care plans in order to ensure the delivery of comprehensive, high-quality, and patient

References

Brooks, L. A., Manias, E., & Bloomer, M. J. (2019). Culturally sensitive communication in healthcare: A concept analysis. Collegian, 26(3), 383–391. https://doi.org/10.1016/J.COLEGN.2018.09.007

Edgman-Levitan, S., & Schoenbaum, S. C. (2021). Patient-centered care: achieving higher quality by designing care through the patient’s eyes. Israel Journal of Health Policy Research, 10(1). https://doi.org/10.1186/S13584-021-00459-9

Handtke, O., Schilgen, B., & Mösko, M. (2019). Culturally competent healthcare – A scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision. PLOS ONE, 14(7), e0219971. https://doi.org/10.1371/JOURNAL.PONE.0219971

Ivanova, J., Grando, A., Murcko, A., Saks, M., Whitfield, M. J., Dye, C., & Chern, D. (2020). Mental health professionals’ perceptions on patient’s control of data sharing. Health Informatics Journal, 26(3), 2011–2029. https://doi.org/10.1177/1460458219893845/ASSET/IMAGES/LARGE/10.1177_1460458219893845-FIG1.JPEG

Molina‐mula, J., & Gallo‐estrada, J. (2020). Impact of Nurse-Patient Relationship on Quality of Care and Patient Autonomy in Decision-Making. International Journal of Environmental Research and Public Health 2020, Vol. 17, Page 835, 17(3), 835. https://doi.org/10.3390/IJERPH17030835

Tobiano, G., Chaboyer, W., Teasdale, T., Raleigh, R., & Manias, E. (2019). Patient engagement in admission and discharge medication communication: A systematic mixed studies review. International Journal of Nursing Studies, 95, 87–102. https://doi.org/10.1016/

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Develop a 20-minute video presentation for nursing colleagues highlighting the fundamental principles of care coordination. Create a detailed narrative script for your presentation, approximately 4-5 pages in length. This is a video presentation.

Effective Care Coordination – Ensuring Comprehensive Patient-Centered Care

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Introduction
This assessment provides an opportunity for you to educate your peers on the care coordination process. The assessment also requires you to address change management issues.

Preparation
You are encouraged to complete the Managing Change activity. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessments.

Scenario
Your nurse manager has been observing your effectiveness as a care coordinator and recognizes the importance of educating other staff nurses in care coordination. Consequently, she has asked you to develop a presentation for your colleagues on care coordination basics. By providing them with basic information about the care coordination process, you will assist them in taking on an expanded role in helping to manage the care coordination process and improve patient outcomes in your community care center.