Care Coordination Presentation to Colleagues

Hello everyone. My name is Samson, and I am delighted to be leading these care coordination foundation sessions. Continuity across care is possible as the backbone of patient-centered care. This discussion today attempts to shed light on the areas of collaboration with patients and families, change management principles, ethical aspects of coordinated care, the influence of a policy on patient results, and to enhance nurses’ core role in the process of care coordination: Care Coordination Presentation to Colleagues.

The Healthcare delivery systems have become more complicated, and nursing practice depends on healthcare systems for providing care; therefore, care coordination plays an imperative role in nursing care. Competent care coordination takes patient outcomes and resource utilization into account and affects the overall quality of care. Hence, it needs the practice of an interdisciplinary nature; healthcare providers, patients, families and community agencies in a concerted and seamless manner. An organized, multidisciplinary approach can help us to enhance patient experiences and outcomes in the field of healthcare.

Now, let’s take a closer look at how nurses can effectively collaborate with patients and families to improve care coordination. Communication between patients and their families, as well as with the teams involved in patient care, is one of the most critical aspects of care coordination. Engagement of the patient in care improves medication compliance, patient satisfaction, and health outcomes. Because of this, nurses must be central to patient education, cultural competence, and shared decision-making so that individuals can assume ownership of their healthcare.

Medication adherence has become a problem, even in cases of chronic diseases such as diabetes, hypertension, and cardiac problems. As per Fallatah et al. (2023), patients are not able to maintain such complicated medication routines. Therefore, they do not follow medication timetables and are faced with negative health consequences. To counteract this, nurses are required to adopt patient-targeted education concentrating on the details of medications, as well as the right use and potential side effects.

For example, creating a medication schedule with pictures for patients who have difficulty reading or using a pill organizer to help them keep track of their medications. Written simplified drug regimens and visual aids to make medication routines easy to follow are also beneficial to patients. Additionally, pharmacist coordination is also important to enhance medication adherence by providing patients with more counselling so that they are fully aware of the prescriptions.

Notably, care coordination also entails cultural competency. Patients are of varied demographics, and their values, traditions, and culture make them healthcare seekers. Feinberg et al. (2021) state that nurses should respect these cultural differences and make changes to the care plans that would accommodate the varying perspectives. For instance, if a patient comes from a culture where direct eye contact is considered disrespectful, the nurse should minimize direct eye contact to build trust.

Bilingual staff, medical interpreters and patient educational materials bridge language gaps and make communication efficient, thereby facilitating patient activation. Additionally, cultural health practices are identified and incorporated into the delivery of care in safe and appropriate ways to further build trust between patients and providers. The culmination of culturally competent care coordination strategies leads to more personalized care and better patient-provider relationships.

Besides, effective care coordination also includes engaging the family. Support networks within families are the main resource of emotional and physical care for patients in the process of controlling their health. Involving the family in care planning, goal setting, and education helps with adherence to treatment plans and sharing of responsibility for good patient care.

Nurses ‘ appreciation of the need for family-centered care can help them educate and support caregivers and empower them to manage their loved one’s condition successfully. For example, when planning care for an elderly patient, involve family members in discussions about the patient’s preferences, routines, and support needs.

As we continue, it is important to recognize that care coordination does not happen in isolation—it requires adapting to change within the healthcare system. The healthcare environment continuously changes, and nurses must stay up to date with new policies, treatments, and patient care methods. Management of change is a part of care coordination since it affects how patients move through transitions in care and also how healthcare teams work together to deliver quality, patient-centred care.

Healthcare change is generally met with resistance since new policies and technologies introduce new, unfamiliar workflows. For example, nurses might resist adopting a new EHR system because they are comfortable with the old system and fear the learning curve associated with the new one. Nurses are critical to effecting change by advocating for evidence-based practices that enhance the delivery of care. Barrow and Annamaraju (2022) describe that an orderly change management process entails efficient communication, staff training, and interprofessional collaboration.

Offering ongoing education and professional development ensures that nurses are skilled at executing new care coordination models. This also addresses nurses’ concerns and increases their confidence in using the new system. Further, it improves patient care by encouraging interdisciplinarity between healthcare professionals who coordinate better and more efficiently with each other when needing to transition care.

The other change determinant for care coordination is technology. The ability of the providers to communicate and patient data availability across care settings are key roles played by electronic health records (EHRs). EHRs limit errors and are more accurate in the documentation, ensuring continuity of care (Kataria & Ravindran, 2020).

Technological innovations have become essential for nurses, integrating seamlessly into practice to enhance patient safety and improve efficiency in patient care. Additionally, telehealth services have expanded access to care, particularly benefiting rural and underserved geographic communities. This expansion allows patients to consult with providers remotely and ensures the continuation of appropriate care through various means.

Care transition improvements must form the focus of the patient-centred transformation initiatives. Preventing preventable hospital readmissions involves using standardized bundled practices such as medication reconciliation and scheduling follow-up appointments. In addition to care coordination navigators, nurse navigators and case managers can help patients transition smoothly from the hospital to home care. Change management initiatives through closing information gaps and maintaining accountability in care transitions facilitate improved patient outcomes and health care experience.

Beyond managing change, ethical considerations play a crucial role in ensuring patient-centered and just care coordination. Ethical principles provide the basis for coordinated care, and they prompt nurses to make knowledgeable decisions that promote patient wellness, autonomy, and justice. Nurses also face frequent ethical challenges when coordinating care for vulnerable patients, dying patients, or patients with discordant healthcare beliefs.

Autonomy is one of the moral principles that need to be maintained in coordinated care. Patients are entitled to make informed decisions concerning their care, even when they go against medical opinions. Nurses are responsible for ensuring that patients get correct, unbiased information regarding their healthcare possibilities so that they can make choices according to their values and wishes (Haddad & Geiger, 2023).

Informed consent is among the most important elements of ethical care coordination because it enlightens patients on their treatment, the risks, and possible alternatives. For instance, if a patient refuses a blood transfusion due to religious beliefs, the nurse must respect the patient’s decision while ensuring they understand the potential consequences.

Consequently, beneficence and nonmaleficence are likewise at the heart of ethical care coordination. Nurses are to provide care that is beneficial to the patient and does no harm. This encompasses medication safety, infection control, and advocating for timely interventions (Haddad & Geiger, 2023).

Ethical care coordination will also involve considering social determinants of health so all patients—irrespective of socioeconomic status—receive access to essential healthcare services. Nurses can advocate for policies that address food insecurity, housing instability, and transportation barriers, which can significantly impact patients’ health outcomes.

Further, justice in care coordination means the distribution of healthcare resources fairly and justly. Nurses are responsible for promoting policies and programs that help eliminate healthcare disparities so that disadvantaged populations also have access to quality care. Ethical dilemmas usually occur when resources are scarce, and nurses need to make tough decisions related to treatment priority and access to care.

During a pandemic, for example, nurses might face difficult decisions about who receives limited resources such as ventilators. By following ethical principles and advocating for patient rights, nurses have a central role in providing equitable and humane care coordination.

In addition to ethics, healthcare policies significantly shape how care coordination is implemented and how patient experiences are influenced. Health policy has a direct impact on care coordination, defining reimbursement models, standards of care, and patient access to care. The Affordable Care Act (ACA) has been a driver in encouraging value-based care, moving reimbursement from volume- to outcome-based systems.

The policy is a quality improvement-focused policy where healthcare organizations are encouraged to adopt care coordination programs that reduce hospital readmission, as indicated by Moy et al. (2023). Value-based payment is a way of paying providers based on the quality and low cost of the care they provide, and, as a result, there are coordinated care programs.

Additionally, Medicaid and Medicare policies simultaneously influence care coordination. The Chronic Care Management (CCM) program offers reimbursement from Medicare for the care coordination services of patients with chronic conditions. At the policy level, the disbursement of capitation has enabled detailed and long-term care planning, which has improved disease management and health outcomes (CMS, 2021). Medicaid expansion has also helped the poor access preventive care services, thus narrowing healthcare disparities and increasing health equity among people experiencing poverty.

The expansion of virtual healthcare services has also changed how care coordination is formed through telehealth policy. Haleem et al. (2021) note that regulatory reforms have expanded reimbursement for telehealth consultations, virtual consults, and remote patient monitoring are available. These policies have helped initiate patients to get their follow-up care on time and thereby prevent avoidable hospital admissions and emergency department visits. However, it is essential to address the digital divide and ensure that all patients have access to telehealth services, regardless of their socioeconomic status or geographic location.

To bring everything together, let us highlight the central role that nurses play in the continuum of care. Nurses are at the forefront of care coordination, both as interdisciplinary cooperation facilitators, educators, and patient advocates. The practice of nurses goes beyond clinical practice to include discharge planning, navigation of community resources, and patient education, as suggested by Karam et al. (2021). Transitional care interventions like comprehensive discharge planning and medication management ensure that patients have continued care after hospital discharge.

Care coordination is strengthened by using community resources so that patients can get the critical services needed to sustain their health and well-being. Patient management of chronic conditions and independence is made possible through home health services, support groups and transportation assistance programs. The nurses refer patients to such resources to promote continuity of care and better patient outcomes. For instance, connecting a patient with diabetes to a local support group or a food bank can improve their overall health and well-being.

In conclusion, the provision of high-quality, patient-centered care requires care coordination. Nurses can significantly enhance quality patient outcomes through the use of effective collaboration strategies, change management, and ethical practices, in addition to supporting policies that nurture care coordination.

Therefore, I encourage each of you to identify one specific action you can take this week to improve care coordination in your practice, whether it’s enhancing your communication skills, learning more about community resources, or advocating for policy changes. By working together, we can create a truly patient-centered system that promotes health, well-being, and equity for all. It is crucial that we are all actively involved in care coordination because we make a direct difference in patients’ health and their well-being.

Thank you for your time and dedication to advancing coordinated, patient-centered care.

References

Barrow, J. M., & Annamaraju, P. (2022). Change management in health care. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459380/

CMS. (2021). Centers for Medicare & Medicaid Services. Cms.gov. https://doi.org/99908

Fallatah, M. S., Alghamdi, G. S., Alzahrani, A. A., Sadagah, M. M., & Alkharji, T. M. (2023). Insights into medication adherence among patients with chronic diseases in Jeddah, Saudi Arabia: A cross-sectional study. Cureus, 15(4). https://doi.org/10.7759/cureus.37592

Feinberg, I. Z., Smith, A. O., O’Connor, M. H., Ogrodnick, M. M., Rothenberg, R., & Eriksen, M. P. (2021). Strengthening culturally competent health communication. Health Security, 19(1). https://doi.org/10.1089/hs.2021.0048

Haddad, L. M., & Geiger, R. A. (2023, August 14). Nursing ethical considerations. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526054/

Haleem, A., Javaid, M., Singh, R. P., & Suman, R. (2021). Telemedicine for healthcare: Capabilities, features, barriers, and applications. Sensors International, 2(2), 100–117. https://doi.org/10.1016/j.sintl.2021.100117

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), 16. https://doi.org/10.5334/ijic.5518

Kataria, S., & Ravindran, V. (2020). Electronic health records: A critical appraisal of strengths and limitations. Journal of the Royal College of Physicians of Edinburgh, 50(3), 262–268. https://doi.org/10.4997/jrcpe.2020.309

Moy, H., Giardino, A., & Varacallo, M. (2023). Accountable care organization. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448136/

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Assessment 3 Care Coordination Presentation to Colleagues

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.

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.

Context
Nurses have a powerful role in the coordination and continuum of care. All nurses must be cognizant of the care coordination process and how safety, ethics, policy, physiological, and cultural needs affect care and patient outcomes. As a nurse, care coordination is something that should always be considered.

Nurses must be aware of factors that impact care coordination and of a continuum of care that utilizes community resources effectively and is part of an ethical framework that represents the professionalism of nurses. Understanding policy elements helps nurses coordinate care effectively.

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 assessment.

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.To prepare for this assessment, identify key factors nurses must consider to effectively participate in the care coordination process.

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 DisabilityServices@capella.edu 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.