Care Coordination Presentation to Colleagues
Care coordination cannot be defined in one dimension and, therefore, varies across many people and settings. Care coordination is a broad nursing and healthcare term used to mean “the deliberate organization of patient care activities between the patient and two or more participants that are involved in the patient’s care to facilitate the appropriate delivery of healthcare services” (Scholz & Minaudo, 2015). Care coordination consists of information management among a multidisciplinary team that is responsible for the different roles and aspects of the patient’s care process, counseling and offering support on healthy behaviors, and provision of adequate resources to meet the patient’s preferences and needs (Scholz & Minaudo, 2015).
Importance of Care Coordination
With the rapid changes in healthcare, care coordination is being implemented by various healthcare settings across the United States to improve health and reduce the burden associated with some of the chronic and acute health conditions. The Institute of Medicine acknowledges the impact of care coordination and ranks it as among the top strategies that can improve efficiency, promote safety, and ensure effectiveness in the healthcare system (Choi, 2017). Patients with chronic diseases such as cancers, diabetes, and mental illnesses find it hard to navigate through the complex health system; this can lead to the deterioration of their conditions or deter them from continuing their care due to follow-up issues that may not be adequately addressed. Care coordination bridges this gap and can help patients align their appointments to avoid tortuous trips to and from different doctors. Care coordination provides an avenue for resource sourcing, which helps the patient offset the unnecessary costs that could accrue from seeking these resources on their own (Hartgerink et al., 2014). Care coordination also allows the multidisciplinary to adequately manage the patient by incorporating an evidence-based model, which is associated with increased patient safety, satisfaction, and health outcomes.
Care Coordination Process
The coordination process is the surest way to make sure that every aspect of this strategy works for all patients. There are several steps that have to be taken into consideration when implementing a care coordination plan. Effective management of patients requires dedicated staff, adequate communication, collaboration with specialists and caregivers, and a clear plan.
The care coordination process is composed of several steps, such as the initial assessment to determine the patient’s problems, needs, barriers to care, and the patient priorities. The next step is the determination of the goals of treatment and desired outcomes. Under this step, three distinct strategies focus on the transition from acute care, chronic care, and prevention (Rushton, 2015). The next phase is targeted at interventions that are considered by the multidisciplinary team with respect to the patient’s issues, needs, goals, and desired outcomes. Under this phase, interventions are grouped under assisting the patient in the access to health care services, ensuring that interventions are evidence-based, and facilitating communication and available resources that would help meet the patient’s needs and goals (Rushton, 2015). The final step is the collection of data, evaluating whether the goals were met, and following up on whether the goals would need modification.
Composition Care Coordination Team
Care coordination is built on the basis of collaboration and a multidisciplinary approach. The essence of care coordination is to ensure that the patient’s needs are adequately met. One way of ensuring this is through the multidisciplinary approach. Studies have shown that the greater the number of staff attending to a patient, the better the outcomes (Mohta et al., 2020). A proper infrastructure, adequate resources, proper communication channels, strong leadership, and a culture that supports coordination efforts are the hallmarks of a care coordination team (Mohta et al., 2020). A properly constituted team will consist of physicians, nurses, pharmacists, family caregivers, specialists, dieticians, social workers, occupational therapists, laboratory technicians, and home healthcare nurses.
Nurses Role in Care Coordination
The roles of the nurses in care coordination are considered the most significant. The fact that a nurse does not miss any multidisciplinary team underscores the nursing role in care coordination. The Institute of Medicine (IOM) recognizes that care coordination is one of the traditional strengths of the nursing profession, whether in the community or the acute care setting” (IOM, 2011, p.65). The nurses have been documented to have an excellent capacity for innovation, problem-solving, and adaptability, and their thorough understanding of the system allows them to engage in multiple levels of healthcare settings (Scholz & Minaudo, 2015).
The role of coordinating is perhaps the most suitable owing to this vast skills, experience, and knowledge. Some of the significant roles nurses play in care coordination include developing. And maintaining positive relationships with team members and patients to promote quality care. The nurses conduct assessments, educate the patients and their families, conduct home visits, initiate and maintain communication with the multidisciplinary team, and manage care transitions (Scholz & Minaudo, 2015).
Involvement of the Family
Care coordination is built on the collaboration between the multidisciplinary team, the patients, and the family of the patient. Family forms a core element of the care process owing to its unique role in understanding the patient at a more personal level. Patients present with complex health needs that can complicate the coordination of care. To optimize care, family involvement is paramount (Banfield et al., 2013). While the multidisciplinary team can implement evidence-based approaches to and strategies for patients, the family can provide pertinent information regarding patients’ preferences, which would significantly impact the care process, therefore improving the care process and clinical outcomes. Previous studies have shown that the involvement of the family in the decision-making process is associated with faster patient recoveries, reduced discomfort, less pain, and significant mental health improvements. The family should work together with the care coordinator and the patient to reinforce the patient’s decisions and preferences during the care process to the overall outcomes (Banfield et al., 2013).
The Code of Ethics for Nurses is the ultimate guide when going about care coordination. The code recognizes the need for respect for human dignity, relationships built on trust and objectivity with no reason for bias or prejudice, maintenance of privacy and confidentiality, and the primacy of patient interests and concerns (American Nurses Association, 2015). Thus, nurses are pushed to maintain high levels of professionalism and exercise competence when implementing evidence-based practices in care coordination.
Care Coordination and the Affordable Care Act
The Affordable Care Act (ACA) is a comprehensive healthcare reform that was set up to improve access and affordability of healthcare in the US. The Act contains provisions on health insurance, access to drugs, and focus on preventive health. In care coordination, preventive efforts are considered part of the plan, and therefore, the significance of the ACA plays a part in this scenario (Edmonds, Campbell & Gilder, 2017). Reductions in costs related to medication and healthcare in general, are part of the care coordination plan. Through insurance reforms and the reduction in drug costs, patient care can be affordable and would promote the improvement of outcomes. ACA is also focused on the state and quality of care and encourages care coordination in the health system (Edmonds, Campbell & Gilder, 2017).
The hallmarks of uncoordinated and fragmented care include poor patient outcomes, lower satisfaction levels, and poor communication. Care coordination is the basis of achieving quality healthcare outcomes. Through the utilization of multidisciplinary teams in healthcare and the incorporation of evidence-based practice, patient needs can be adequately met, thus improving the patient’s quality of life. The goal of coordination of care is to deliver patient-centered care in a seamless and coordinated manner.
American Nurses Association. (2015). Code of Ethics for Nursing with Interpretive Statements. Retrieved from https://www.nursingworld.org/practice- policy/nursing excellence/ethics/code-of-ethics-for-nurses/coe-view-only/
Banfield, M., Gardner, K., McRae, I., Gillespie, J., Wells, R., & Yen, L. (2013). Unlocking information for coordination of care in Australia: A qualitative study of information continuity in four primary health care models. BMC Family Practice. https://doi.org/10.1186/1471-2296-14-34
Choi, Y. (2017). Care Coordination and Transitions of Care. In Medical Clinics of North America. https://doi.org/10.1016/j.mcna.2017.06.001
Edmonds, J. K., Campbell, L. A., & Gilder, R. E. (2017). Public Health Nursing Practice in the Affordable Care Act Era: A National Survey. Public Health Nursing. https://doi.org/10.1111/phn.12286
Hartgerink, J. M., Cramm, J. M., Bakker, T. J. E. M., van Eijsden, R. A. M., Mackenbach, J. P., & Nieboer, A. P. (2014). The importance of relational coordination for integrated care delivery to older patients in the hospital. Journal of Nursing Management. https://doi.org/10.1111/j.1365-2834.2012.01481.x Institute of Medicine. (2011). The Future of Nursing: Leading change, advancing health.
Washington, DC: The National Academies Press, from http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-ChangeAdvancing- Health.aspx
Mohta, N. S., Prewitt, E., Gordon, L., Porter, M. E., & Lee, T. H. (2020). Introducing NEJM Catalyst Innovations in Care Delivery. NEJM Catalyst, 1(1), CAT.19.1111. https://doi.org/10.1056/CAT.19.1111
Penm, J., MacKinnon, N. J., Strakowski, S. M., Ying, J., & Doty, M. M. (2017). Minding the Gap: Factors Associated With Primary Care Coordination of Adults in 11 Countries. The Annals of Family Medicine, 15(2), 113–119. https://doi.org/10.1370/afm.2028
Rushton, S. (2015). The Population Care Coordination Process. Retrieved from https://alliedhealth.ceconnection.com/files/ThePopulationCareCoordinationProcess14406 81712212.pdf
Scholz, J., & Minaudo, J. (2015). Registered nurse care coordination: Creating a preferred future for older adults with multimorbidity. Online Journal of Issues in Nursing. https://doi.org/10.3912/OJIN.Vol20No03Man04
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INSTRUCTIONS-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.
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.
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.
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Review the assessment instructions and scoring guide to ensure you understand the work you will be asked to complete.
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