Care Coordination Presentation to Colleagues

Hello, and welcome to today’s session on care coordination. My name is Jessica Durkin, and I am excited to guide you through care coordination, one of the most critical aspects of nursing. As nurses, we are at the forefront of putting into practice the principles of patient-friendly care and coordinating care in different contexts of care delivery. As such, we will discuss the basic concepts of care coordination, how care can be effectively provided to patients and their families, the ethics, the concept of change management, and the impact of healthcare policies.

[Introduction to Care Coordination]

Care coordination is the process of organizing patient care activities and ensuring that all participants involved in a patient’s care are working together to achieve safer and more effective care. The objective of care coordination is, therefore, to address people’s needs, deliver appropriate care at the right time, and optimize their health status. Thus, this not only involves the healthcare team but also patients and their families. Appropriate care management minimizes care gaps and, thereby, the risk of relapse and medical errors, as noted by Khatri et al. (writing in 2023).

Nurses are vital in this process. We are the connectors that deliver pieces of a patient’s healthcare puzzle and make them whole. Whether during changes in shifts, for disorders with long-term treatment plans, in multimodal care, or when communicating with numerous other specialists, nurses are the backbone in ensuring that patients receive appropriate treatment at the right time and place. In today’s topic, it will be highly beneficial to know how nurses can advance in their care coordination performance and how they can address various patient concerns.

[Effective Strategies for Collaborating with Patients and Families]

One of the most important aspects of care coordination is collaboration with healthcare providers and patients and their families. Notably, effective care relies on the active engagement of patients and their families in the care process. In addition, in 2021, Karam et al. noted that this engagement begins with clear, patient-centered communication.

For example, providing educational interventions that are tailored to a patient’s cultural background is essential. Cultural competence in nursing ensures that nurses respect and integrate the diverse beliefs, values, and preferences of patients into their care. Let us take the case of a diabetic patient who primarily speaks Spanish. By using bilingual education materials and involving an interpreter in his care plan discussions, we can improve his understanding of his condition and enhance his medication adherence. This is an example of culturally sensitive care that leads to better outcomes.

We can also adopt clinical support tools such as telehealth to enhance patient healthcare-provider communication. Telehealth enables healthcare professionals to stay connected with patients and participate in the management of chronic diseases from the confines of their homes. For example, the application of tracking symptoms and compliance with medications propels patients and families into an active role in self-management, thus minimizing admissions.

[Change Management in Care Coordination]

Change is inevitable in healthcare, and managing that change is critical to improving patient outcomes and maintaining high-quality care coordination. Change management involves implementing new practices and technologies in a way that minimizes disruption and enhances patient care. One of the best examples of change management is the adoption of electronic health records (EHR) in our healthcare systems. As a result of EHR, data can be shared between many centers. Besides, EHR ensures that patients are consistently managed, and this eliminates errors.

However, not every change is welcomed, and it most often meets some form of resistance from the staff. That is where leadership in nursing comes in. Thus, as nurses, we need to demonstrate the necessary engagement in different training programs and accept the newest technologies useful in the coordination of care. Education intervention to engage the nurses on some new devices like EHRs or telemedicine comprises pivotal helpful factors in overcoming the resistance during implementation. When staff is adequately trained and engaged in the change process, patient outcomes improve, and care coordination becomes more effective.

By managing these changes proactively, Cheraghi et al. (writing in 2023) note that we ensure that patients experience a smoother healthcare journey, from hospital admission to post-discharge follow-up.

[Ethical Decision-Making in Coordinated Care Plans]

Ethics is a core component of nursing and plays a crucial role in care coordination. We are often faced with decisions that affect the well-being of our patients, and these decisions must be guided by ethical principles, including autonomy, beneficence, non-maleficence, and justice.

Consider, for instance, a situation where a patient refuses a life-saving treatment. While respecting their right and ability to make their own decisions, it is also imperative that they know about the result of that decision. That is why the concept of shared decision-making comes into the frame. Thus, we ensure that the care plan reflects the patient’s values and preferences and is safe and effective, which is provided by ethical duties.

Additionally, we have to be able to guarantee that every patient receives treatment based on their needs, irrespective of their financial status, race/ethnicity, or where they are from. Ethical care coordination integrates the voices of the marginalized into advocacy in order to close the gaps in the organization of care delivery with clients or patients. Our role is to use community resources or telehealth to reach underprivileged areas and ensure that every patient gets the needed care.

[Healthcare Policy and Its Impact on Care Coordination]

Healthcare policies have a significant impact on how we deliver care, and understanding these policies is crucial for effective care coordination. Policies such as the Affordable Care Act (ACA) and Medicare/Medicaid regulations have incentivized care coordination models that focus on improving patient outcomes while reducing costs.

One example of how healthcare policy affects care coordination is the implementation of value-based purchasing programs. The purpose of these programs is to present added incentives to healthcare facilities in order to enhance patient care and clinical results. For example, although Medicare now pays hospitals for the services it requires, facilities that achieve lower readmission rates or better chronic disease care get more from Medicare to cover the cost. According to Teisberg et al. (2020), this policy puts pressure on hospitals and healthcare providers to adopt the management and delivery of care patterns that will bring meaningful change and positive consequences to patients and the healthcare system as a whole.

Another policy-driven innovation that has benefited care coordination, particularly during the COVID-19 pandemic, is telehealth services. Telehealth can help with the early identification of patients’ need for care, as well as ongoing tracking of and post-acute plans for patients, all of which have been critical in addressing chronic diseases and the strain on health systems.

[The Nurse’s Vital Role in the Continuum of Care]

As nurses, we are the frontline of care coordination. Regardless of whether we are working to facilitate a transition from hospital to home or planning for the patient’s ongoing care, we are a key component of a patient’s care journey and experience. Our role is not just to provide clinical care but also to communicate with interdisciplinary teams, advocate for patients, and ensure that care plans are followed through.

In many cases, nurses are the professionals who catch potential issues before they become problems. For example, during a discharge planning meeting, a nurse may identify that a patient does not have adequate support at home to manage their medications. By coordinating with social workers, home health aides, and the patient’s family, the nurse can ensure that the patient has the necessary resources in place to avoid readmission.

[Conclusion]

In conclusion, care coordination is an essential part of nursing care that enhances patient satisfaction and optimizes the delivery of healthcare services. When working with patients and their families, change in the practice, decision-making, and understanding policies in the healthcare setting, we are able to improve the care we offer our patients and impact their quality of life.

As nurses, we are in a unique position to lead the charge in improving care coordination. Therefore, applying the lessons gained from this session in our daily practice can ensure that our patients receive the best possible care. Notably, we are all key players in care coordination and improving patient care.

Thank you!

References

Cheraghi, R., Ebrahimi, H., Kheibar, N., & Sahebihagh, M. H. (2023). Reasons for resistance to change in nursing: An integrative review. BMC Nursing, 22(1), 1–9. https://doi.org/10.1186/s12912-023-01460-0

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

Khatri, R., Endalamaw, A., Erku, D., Wolka, E., Nigatu, F., Zewdie, A., & Assefa, Y. (2023). Continuity and care coordination of primary health care: A scoping review. BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-09718-8

Teisberg, E., Wallace, S., & O’Hara, S. (2020). Defining and implementing value-based health care. Academic Medicine, 95(5), 682–685. https://doi.org/10.1097/acm.0000000000003122

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You may also wish to:

• Review the assessment instructions and scoring guide to ensure you understand the work you will be asked to complete.
• Allow plenty of time to rehearse your presentation.

Recording Equipment Setup and Testing
Check that your recording equipment and software are working properly and that you know how to record and upload your presentation. You may use Kaltura (recommended) or similar software for your audio recording. A reference page is required. However, no PowerPoint presentation is required for this assessment.

• If using Kaltura, refer to the Using Kaltura tutorial for directions on recording and uploading your video in the courseroom.

Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact [email protected] to request accommodations.

Care Coordination Presentation to Colleagues

Instructions
Complete the following:

• Develop a video presentation for nursing colleagues highlighting the fundamental principles of care coordination. Include community resources, ethical issues, and policy issues that affect the coordination of care. To prepare, develop a detailed narrative script. The script will be submitted along with the video.

Note: You are not required to deliver your presentation.

Presentation Format and Length

• Create a detailed narrative script for your video presentation, approximately 4–5 pages in length. Include a reference list at the end of the script.

Supporting Evidence

• Cite 3–5 credible sources from peer-reviewed journals or professional industry publications to support your video. Include your source citations on a references page appended to your narrative script. Explore the resources about effective presentations as you prepare your assessment.

Grading Requirements
The requirements outlined below correspond to the grading criteria in the Care Coordination Presentation to Colleagues Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

• Outline effective strategies for collaborating with patients and their families to achieve desired health outcomes.
  • Provide, for example, drug-specific educational interventions, cultural competence strategies.
  • Include evidence that you have to support your selected strategies.
• Identify the aspects of change management that directly affect elements of the patient experience essential to the provision of high-quality, patient-centered care.
• Explain the rationale for coordinated care plans based on ethical decision making.
  • Consider the reasonable implications and consequences of an ethical approach to care and any underlying assumptions that may influence decision making.
• Identify the potential impact of specific health care policy provisions on outcomes and patient experiences.
  • What are the logical implications and consequences of relevant policy provisions?
  • What evidence do you have to support your conclusions?
• Raise awareness of the nurse’s vital role in the coordination and continuum of care in a video-recorded presentation.
  • Fine tune the presentation to your audience.
  • Stay focused on key issues of import with respect to the effects of resources, ethics, and policy on the provision of high-quality, patient-centered care.
  • Adhere to presentation best practices.

Additional Requirements

• Submit both your presentation video and script. The script should include a reference page. See Using Kaltura for more information about uploading multimedia files. You may submit the assessment only once, so be sure that both assessment deliverables are included.

Portfolio Prompt: Save your presentation to your ePortfolio. Submissions to the ePortfolio will be part of your final Capstone course.