Care Coordination Presentation to Colleagues

Hello and welcome to this Care Coordination Presentation. My name is Simone Williams. In this presentation, I’ll start by discussing Effective Strategies for Collaborating with Patients and their Families to achieve desired Health Outcomes. I’ll then discuss Aspects of Change Management that directly affect Elements of Patient Experience essential to the Provision of High-quality Patient-Centered Care. Next, I’ll discuss The Rationale for Coordinated Care Plans based on Ethical Decision Making and the Potential Impact of Specific Health Care Policy Provisions on Outcomes and Patient Experiences. Lastly, I’ll discuss the Nurse’s Vital Role in the Coordination and Continuum of Care.

Effective Strategies for Collaborating with Patients and their Families to achieve desired Health Outcomes

There is a need for increased patient engagement regarding individual interactions with healthcare practitioners. Some research studies, such as the one conducted by Lee et al. in 2010, show that clinicians and patients have different perspectives on the significance of health goals and healthcare risks. Other studies have shown that physicians do not have accurate perceptions of the health beliefs of their patients, but they assume that their patients’ beliefs are often aligned with theirs. According to authors Street and Haidet, 2011, this misperception would improve if patients were allowed to participate in the consultation actively. Some studies, like the one conducted by Smith et al. (2013 have also found that physicians tend to interrupt patients within fifteen seconds of their starting to speak during their visit, but when patients are uninterrupted, they tend to conclude within a minute. Healthcare professionals must be prepared with communication techniques and skills to optimize patient engagement opportunities. Therefore, the best strategy to employ first is training in communication skills. Besides, Smith et al. (2013) argue that patients, caregivers, and the patient’s families can bring vital knowledge to bear on health care if they are invited. This cannot be achieved within a single visit only. Physicians need to ask patients whether there is something else that needs discussing rather than asking whether there is anything else. Research by multiple authors, including Heritage (writing in 2007), shows that the question of whether there is something else has, in the past, minimized the number of unmet concerns by about 80%. Additionally, patients bring a distinct view to the encounter than clinicians and also introduce different information. For instance, patients who are on statin drugs are more likely than clinicians to start a discussion on the symptoms that are potentially related to the prescription.

Another important strategy that would improve health outcomes is shared decision-making. While letting patients know about their options is significant, genuine patient-centered care needs a new decision-making model whereby responsibility is shared between the clinician and the patient. According to multiple authors, including Smith (writing in 2013), clinicians and patients have to work together in managing intricate conditions, as well as making decisions based on the best scientific evidence and the patient’s life circumstances, values, preferences, and biological characteristics. Where trade-offs need to be considered, clinicians must discuss the benefits and risks of the competing treatment and diagnostic alternatives with the patients and their caregivers.

According to multiple authors, including Smith (writing in 2013), patients must be engaged at the organizational level. At the organizational level, engaging patients implies various things, including creating patient and family councils, creating portals for patients to allow them to access their health information, and coming up with policies that would allow for timely access to care. Because patients, their caregivers, and their families are the groups that experience care, their views can be very instrumental in efficient and effective healthcare organizations. According to multiple authors, including Smith (writing in 2013), their knowledge, therefore, needs to be leveraged to enhance the care experience through the application of their knowledge to the delivery and design of care in healthcare organizations- inclusive of visiting hours, hospital design, and care delivery.

Another critical strategy is engaging patients at the system level. According to Smith et al. (2013), constant assessment of the patient experience can be utilized in supporting patient-centered care across a healthcare setting continuum while at the same time providing the chance to enhance better coordination of services, transitions, and integration. Methods for measuring care must be developed to support payment and reform approaches that reward patient-centered care. For instance, the use of an instrument such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) helps in prompting reports from patients regarding their experiences in their interactions with the healthcare system, their interactions with healthcare staff, the provided information, general satisfaction of the patient with the care experience as well as the patient’s willingness to recommend the health care institution to other people. Such a strategy is essential as it would help in analyzing the patient experience and implementing best practices to improve patient experiences and care outcomes.

Aspects of Change Management that directly affect Elements of Patient Experience essential to the Provision of High-quality Patient-Centered Care

One aspect of change management that directly affects the elements of patient experience is the involvement of healthcare professionals in the change. In Nilsen et al. (2020) ‘s research study, physicians emphasized the significance of a bottom-up approach when it came to change. Since healthcare professionals are people on the ground, the most innovative ideas are likely to emerge from their level, and this is likely to lead to responsiveness. In the Nilsen et al. (2020) study, one registered nurse states that if employees are included from the start and believe in the change, then there is a high chance of the change’s success. However, many employees in this study complained about the hierarchy of the healthcare system, which creates a long distance such that healthcare professionals cannot influence change management because it is mainly undertaken at higher or political management levels. On that note, it is essential to have people who know the actual care work participate in change management because they closely interact with the patients, their families, and the caregivers.

Another important aspect is communication. An effective change management would have open lines of communication to avoid disparities and resistance to change. Nilsen et al. (2020) argue that nurses are likely to resist change, especially if they perceive that it was implemented unexpectedly or without previous communication. This leaves the critical stakeholders of the change uninformed and powerless. In such a case, a nurse is not likely to be prepared for the change, affecting their effectiveness in delivering care to patients, their families, and caregivers.

The key stakeholders need to understand the need for the change and how it is going to benefit the organization as well as the patients. This leads to another influential aspect of change management, that is, value for change. The health care professionals need to feel that the change proposed is not done since the region has already decided but because they believe that the change would make health care better.

The Rationale for Coordinated Care Plans Based on Ethical Decision Making

According to Tønnessen, Ursin & Brinchmann (2017), the need for healthcare and nursing has generally exceeded the available resources. Therefore, the healthcare services allocation often implies ethical dilemmas. In this case, health care professionals face various moral decisions in their daily practice, meaning there is a need for care coordination that operates on an established ethical standard. Moreover, coordination of care requires that healthcare efficiencies are realized by considering the preferences and needs of the patients, their families, and caregivers. More often than not, as Tønnessen, Ursin & Brinchmann (2017) found, healthcare professionals find themselves in ethical dilemmas, especially when the beliefs of their patients are not in line with their own beliefs. Therefore, their decision-making will primarily be guided by the ethical tenets of deontology and utilitarianism as guided by what outcomes are more beneficial or fair and what the roles and responsibilities of the care coordinator are. Coordinated care plans are therefore necessary to help make informed decisions since individual decision-making may be based on a person’s views, beliefs, and preferences contrary to the desired or effective health outcomes.

Potential Impact of Specific Health Care Policy Provisions on Outcomes and Patient Experiences

The Affordable Care Act is the most critical healthcare policy that aimed at increasing health insurance coverage in the U.S. since the Medicaid and Medicare programs were implemented in 1966. According to Kominski, Nonzee, and Sorensen (2017), by 2016, approximately 20 million people had health insurance coverage, which was way more than the previous three years. Low-income patients have been the key beneficiaries of this initiative in Medicaid-expanded states. However, there have been challenges with this policy. Low-income people deemed eligible to receive insurance coverage remain uninsured because of availability concerns. This is because some of them live in states that have not embraced Medicaid expansion, and some are undocumented and, therefore, prohibited from receiving ACA benefits.

Nurse’s Vital Role in the Coordination and Continuum of Care

In summary, to ensure effective and efficient care coordination, nurses need to share knowledge about patient care with the other members of the care teams to ensure seamless transitions of care. They should also collaborate with the various healthcare providers to develop a proactive care plan to manage the patient’s needs. In their role in care coordination, they need to support the patients in the management of their healthcare goals, inclusive of linking them with the resources within the community.

References

Heritage, J., Robinson, J. D., Elliott, M. N., Beckett, M., & Wilkes, M. (2007). Reducing patients’ unmet concerns in primary care: the difference one word can make. Journal of General Internal Medicine, 22(10), 1429-1433.

Kominski, G. F., Nonzee, N. J., & Sorensen, A. (2017). The Affordable Care Act impacts access to insurance and health care for low-income populations. Annual review of public health, 38, 489-505.

Lee, C. N., Hultman, C. S., & Sepucha, K. (2010). Do patients and providers agree about the most important facts and goals for breast reconstruction decisions? Annals of plastic surgery, 64(5), 563-566.

Nilsen, P., Seing, I., Ericsson, C., Birken, S. A., & Schildmeijer, K. (2020). Characteristics of successful changes in health care organizations: an interview study with physicians, registered nurses, and assistant nurses. BMC Health Services Research, 20(1), 1-8.

Smith, M., Saunders, R., Stuckhardt, L., & McGinnis, J. M. (2013). Engaging patients, families, and communities. In Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. National Academies Press (U.S.).

Street, R. L., & Haidet, P. (2011). How well do doctors know their patients? Factors affecting physician understanding of patients’ health beliefs. Journal of General Internal Medicine, 26(1), 21-27.

Tønnessen, S., Ursin, G., & Brinchmann, B. S. (2017). Care-managers’ professional choices: ethical dilemmas and conflicting expectations. BMC Health Services Research, 17(1), 1-10.

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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, and record a video of your presentation.

Introduction
Nurses have a decisive role in the coordination and continuum of care. All nurses must know 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.

This assessment allows 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 primary 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 critical factors nurses must consider to participate in the care coordination process effectively.

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.
Note: Remember that you can submit all or a portion of your draft presentation to Smarthinking Tutoring for feedback before you submit the final version of this assessment. If you plan on using this free service, be mindful of the turnaround time of 24-48 hours for receiving feedback.

Recording Equipment Setup and Testing
Check that your recording equipment and software are working correctly 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 courtroom.
Note: If you require 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 care coordination. 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. 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 address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

Outline effective collaboration strategies for 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 providing 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 importance concerning 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 ensure 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 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 collaboration strategies for 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 providing 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.