Care Coordination Presentation for Colleagues
Hello, My name is Maria Robinson; as most of you know, I have been a nurse here for just over 4 years. I have been asked to share some information regarding care coordination. In this presentation, I will explain what care coordination is and what effect it has on positive patient outcomes, what it entails, and how ethics are intertwined. We all became nurses with a passion for caregiving, helping people heal from and prevent illness, to nurture and educate on healthy lifestyle choices. All of this is a part of care coordination and patient-centred care.
What is care coordination?
Synchronization of the delivery of the patient’s health care from multiple providers, the goals of care coordination are to improve positive outcomes by ensuring that the care provided by multiple providers is not delivered haphazardly and to help reduce healthcare costs (NEJM Catalyst, 2018).
Importance of care coordination
Care coordination is crucial to the patient and positive outcomes. According to Dr. Botsford in an online article from 2017, “poor care coordination creates negative consequences for both patients and healthcare providers” [ CITATION Bea17 \l 1033 ]. Another physician in the same article goes on to state that inadequate care coordination is a systemic issue across the healthcare industry after a personal experience with his dog. The veterinarian providing his dog’s care took as long as was needed to give detailed instructions for care for his dog at home. This made him realize that this veterinarian spent more time with him regarding his dog than he himself does with preparing a human for discharge home. Medication reconciliation is an equally important factor in care coordination for positive outcomes. Ensuring the patient is leaving with the correct medications prescribed as well as the education regarding these and the importance of self-care by taking the prescribed medications as directed to help prevent readmission.
Steps of care coordination
We use the nursing process to coordinate plans for care every day. The “nursing process incorporates an interactive and interpersonal approach with a problem-solving and decision- making process that serves as a framework for the delivery of nursing care” (Doenges et al., p.4, 2013). This involves collecting data, identifying patient needs, establishing goals with meaningful and measurable outcomes, and using individualized nursing interventions to assist the patient in achieving the set goals for a positive outcome. Combined with collaborative care made up of the entire care team and you have care coordination.
Who is the care team made of?
That is easy; the care team is made up of all of us – Nurses, physicians, care techs, pharmacists, dietitians, therapists, and social/case workers – anyone that interacts with the patient on their journey of healing.
Elements of care coordination according to (NEJM Catalyst, 2018):
Easy access to a range of healthcare services and providers
Good communication and effective care plan transitions between providers
A focus on the total healthcare needs of the patient
Clear and simple information that patients can understand
Types of care coordination
Primary care coordination: Includes preventative health and providing care for patients with chronic diseases and conditions. Using The Guided Care Model developed by Johns Hopkins University researchers to handle the growing challenge of caring for an aging America mentioned by (NEJM Catalyst, 2018). “This proven care model, and trained Guided Care nurse works closely with patients, physicians, and others to provide coordination, patient-centered care” (Johns Hopkins Bloomberg School of Public Health).
Acute care coordination: Includes patients with acute or emergent health problems such as stroke or heart attack. These patients receive care first by emergency medical services. The risk of communication breakdown, medication errors, and redundancies can increase in these hectic situations. The focus on communication with provider hand-off in these situations is highly important for success and for creating positive outcomes for patients (NEJM Catalyst, 2018). In acute care settings, there is often a transition of care programs that include setting up hospital follow-up appointments, ensuring prescriptions are sent and filled at the proper pharmacy, and instructions are provided for the patient and family or caregiver. The ultimate goal of the transition care program is to help reduce hospital readmission rates (NEJM Catalyst, 2018).
Post-acute/long-term care coordination: some patients who leave acute care may go on to post-acute or skilled nursing facilities to work with therapies to build up their strength and return home. Some are successful with this, and some may have to move to different levels of care within the same or even a different facility for long-term care. In successful models, care coordinator such as licensed social workers facilitates the transition with the patient and their loved ones to ensure that everyone is on the same wavelength with the care plan and expectations of care (NEJM Catalyst, 2018).
Include family
It is not often that you come across a patient who does not have family present to advocate for their loved one. Taking the family’s input into consideration when providing care is just as important as including the patient. Especially if the patient is not alert or oriented to speak for themselves, as nurses, we must realize that communication with family is just as important and that we are in fact trained to communicate with family as well as patients to build rapport and partnership to help prevent further complications and make a positive outcome more possible, (Belanger, Bourdonnais, Bernier, & Benoit, p. 609, 2016).
Ethical considerations
The Code of Ethics for Nurses should be followed when considering the need for care coordination. The Code calls for nurses to respect that each individual patient has their own specific needs. Nurses are pushed to maintain competence in their profession, using evidence-based practices, clinical expertise, and patient values to comprise the individual plan of care for each patient (Doenges et al.r, p. 4-5, 2013).
ACA in relation to care coordination educating the patient population
“Better health outcomes are linked directly to health literacy. The Patient Protection and Affordable Care Act of 2010, Title V, defines health literacy as the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions” (May, p.53, 2018). The bedside or primary RN must be able to determine the patient’s ability to understand and their style of learning that would best promote the ability to retain the information to positively influence their own health outcomes.
Conclusion
In conclusion, collaborative care coordination is one of the most important factors for ongoing care and the best way to ensure positive patient outcomes. Please take this information into consideration when developing care plans for your patients. Do not hesitate to contact me with any questions. Thank you for taking the time out of your day. Are there any questions that you have for me right now?
References
Bean, M. (2017, February 28). Becker’s Clinical Leadership & Infection Control. Retrieved from Beckers Hospital Review: https://www.beckershospitalreview.com/quality/the- importance-of-care-coordination-in-a-value-based-world-lessons-learned-by-spectrum- health.html
Belanger, L., Bourdonnais, A., Bernier, R., & Benoit, M. (2016). Communication between nurses and family caregivers of hospitalized older persons: a literature review. Journal of Clinical Nursing, 26(5-6), 609-619.
Doenges , M. E., Moorhouse, M. F., & Murr, A. C. (2013). Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care. F.A. Davis Company.
Johns Hopkins Bloomberg School of Public Health. (n.d.). Guided Care. Retrieved from Comprehensive Primary Care for Complex Patients: http://www.guidedcare.org/
May, A. J. (2018, Janurary-February). Diabetes, health literacy, and the importance of care coordination. Medsurg Nursing, 27(1), 53-54.
NEJM Catalyst. (2018, January). NEJM Catalyst. Retrieved from Innovations in Care Delivery: https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0291
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Question 
Develop a 20-minute 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, and record a video of your presentation.
Introduction
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.
Care Coordination Presentation for Colleagues
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. 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.
Preparation
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 course room.
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.
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, and 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 and 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 healthcare 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.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
Competency 2: Collaborate with patients and families to achieve desired outcomes.
Outline effective strategies for collaborating with patients and their families to achieve desired health outcomes.
Competency 3: Create a satisfying patient experience.
Identify the aspects of change management that directly affect elements of the patient experience essential to the provision of high-quality, patient-centered care.
Competency 4: Defend decisions based on the code of ethics for nursing.
Explain the rationale for coordinated care plans based on ethical decision-making.
Competency 5: Explain how healthcare policies affect patient-centered care.
Identify the potential impact of specific healthcare policy provisions on outcomes and patient experiences.
Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.
Raise awareness of the nurse’s vital role in the coordination and continuum of care in a video-recorded presentation.