NURS FPX 6618 Assessment 1 – Planning and Presenting a Care Coordination Project
The Importance of Collaboration with Patients and Their Families
Care coordination is identified by the American Nurses Association (2012) as a core professional standard for all registered nurses (Yoder, 2017, p. 225). Focusing on the coordination of care between patients, their families, and multiple disciplinary teams. Therefore, it is crucial for nurses to be fluent in care coordination and transition management (CCTM). Creating an environment that enhances patient experiences, improves population health, reduces costs, and improves the caregiver experience (Yoder, 2017, p. 225).
Coordination of care should begin as soon as the patient enters the emergency department and will continue long after that patient is discharged. When a patient enters the hospital, it is the responsibility of the nurse to determine that patient’s unique learning style. Every patient is unique, and therefore so is the way they learn and process information. Some patients learn through reading, while others learn through writing. Then there are patients who benefit from being able to teach back the material they have learned. There are multiple opportunities for education during a patient’s hospital stay. For the nurse to be able to take advantage of these opportunities, it is crucial that the patient’s learning style is determined early. Once determined, the nurse should then focus on the four core concepts of patient and family-centered care. These concepts include focusing on dignity and respect, information sharing, patient participation, and collaboration (Johnson, 2016).
NURS FPX 6618 Assessment 1 – Planning and Presenting a Care Coordination Project
Core Concepts of Patient & Family Centered Care
As a healthcare professional, it is your duty to truly listen to your patient’s wants and needs. As well as honor and respect their wishes. Not every patient has the same values and cultural beliefs. Therefore, it is important to determine any cultural beliefs that may be important to the patient while planning their care. For example, Jehovah’s Witnesses believe that humans must not sustain their life with another creature’s blood and that there is no distinction between taking blood into their mouth and their blood vessels (Olaussen et al., 2018). Because of these beliefs, Jehovah’s Witnesses are unable to receive blood transfusions.
After determining what cultural beliefs or values may weigh in on the patient’s care, it is then important for the nurse to focus on sharing information with the appropriate parties involved. This includes the sharing of information between providers and the sharing of information between patients and their family members. When communication is done well, it can create one unified plan of care. When done poorly, it creates a confusing environment for the patient and their loved ones. Just the other day, I experienced a situation just like this where communication between providers failed, leaving the patient and their family members confused and concerned about the treatment plan. This patient was suffering from a very serious case of necrotizing pancreatitis. Both hospitalists and gastrointestinal physicians agreed the patient would require a GJ tube to be placed. This allows for the patient to have complete bowel rest for one to two months before resuming intake. A third physician later came in, telling the patient he could resume eating on a clear diet for the time being. This type of contradicting information created a sense of worry and frustration for the patient and their loved ones. This a problem that could have been avoided if proper communication was utilized between all parties involved in the patient’s care.
After a good line of communication is established, it is important to focus on the last two core concepts, participation, and collaboration. As healthcare providers, it is critical to create an environment where patients feel comfortable participating in their plan of care. While creating this environment, it is important for the nurse to first make sure the patient is at a point where they are willing to participate. Once establishing that there is a will to participate, it is then important to make sure you’re in an environment free from distractions. Once both are established, it is important for that nurse to embody active listening skills. This can be accomplished by focusing on the use of proper body mechanics, including directly facing the patient at eye level while making sure not to be standing over the patient. While communicating with the patient, it is important to make sure that they fully understand the information that you are presenting to them. By utilizing techniques such as teach-back, the nurse determines the level of understanding while having the patient fully participate in their education.
Finally, due to the complexity of caring for patients, hospitals require collaboration between multiple types of health professionals as well as patients and their families. Without effective collaboration, the patient’s health and hospital experience would suffer greatly. Not only are nurses responsible for collaborating with physicians they are also responsible for collaborating with caseworkers. Without adequate collaboration, patients may not receive the proper tools or equipment needed for a safe recovery.
NURS FPX 6618 Assessment 1 – Planning and Presenting a Care Coordination Project
Change Management and Patient Satisfaction
In 2006, the Center for Medicare and Medicaid Services implemented the Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS) (McFarlan et al., 2019). HCAHPS survey is composed of questions that rate the overall patient satisfaction and quality of care as well as the patient’s wiliness to recommend the hospital. Patient satisfaction and quality of care can be directly correlated to change management. One-way hospitals improve quality patient care is by utilizing Lewin’s Change Management Theory. This theory is composed of three steps; unfreezing, changing, and refreezing, all with a common goal of creating a smooth transition when it comes to change.
If we go back to the example used earlier involving the lack of communication between physicians, I can better explain this theory. If the nurse had not realized there was a breakdown of communication between physicians, it would have ultimately led to her supplying fluids to the patient before he was ready. This would then lead to a delay in care for the patient due to the surgeon’s inability to perform the surgery. Causing frustration, dissatisfaction, and a lack of trust between providers and the patient.
Now let’s apply Lewin’s Change Theory while coming up with a solution for this situation. In the first phase, unfreezing, it would be important to present the problem. In this case, it would be poor communication between the physicians, nurse, and patient. During the first phase, it is crucial to have support from management as well as any higher staff involved.
During the second phase it is important to develop a plan that focuses on the change. Our plan would focus on improving communication between staff members as well as the patients by utilizing some sort of tool. By creating a plan, you are now implementing the project. Education is crucial during this stage. You need to educate not only on what is changing but what is expected from each member. Finally, during the refreezing stage, changes are reinforced, creating a more positive experience for the patient. It is important during this stage to recognize what was done well by the staff.
Ethical Decision-Making in Care Planning
There are many complex situations that can occur when you are responsible for another person’s life. It is your responsibility, as a nurse, to follow the Code of Ethics for Nurses. This code embodies autonomy, utility, harmlessness, honesty, privacy, justice, and loyalty toward our patients. Being able to educate our patients is a huge reasonability as a nurse. It is our duty to provide education on options available when it comes to their care, but we should not persuade them when it comes to any decisions they make involving their care. It is also our responsibility to make sure that every patient gets the necessary resources they need, no matter what their race, gender, sexual preference, or their social status.
NURS FPX 6618 Assessment 1 – Planning and Presenting a Care Coordination Project
Policies Involving Health Care
Programs such as the Hospital Readmission Reduction and the Affordable Care Act were set up with one goal in mind, protecting our patients. The Hospital Readmission Reduction Program is a Medicare value-based purchasing program encouraging hospitals to improve communication and care coordination. This program focuses on six healthcare conditions with the goal of avoiding unnecessary readmission by engaging patients and their caregivers more in their discharge plans (Hospital Readmissions Reduction Program (HRRP), 2020). While the Affordable Care Act (ACA) is an important government policy that was created to improve access for patients while elevating the quality of care and reducing healthcare expenditures (Collins & Saylor, 2018, p. 43). The ACA also prevents any discrimination against patients suffering from preexisting conditions.
Your Role as a Nurse
As patient advocates, it is our responsibility to do no harm to our patients. They also play an important role when it comes to the coordination and continuum of care. Being that they spend the majority of their day in direct contact with their patients. This allows them the unique opportunity to not only provide quality education but to understand their patient’s concerns and needs. Making them a great tool for physicians and case management to utilize during their transition out of the hospital. With care coordination being a priority across the healthcare spectrum, it is important to focus on the utilization of registered nurses to create a positive experience when it comes to care coordination.
References
Anderson, A., & Hewner, S. (2021). Care coordination: A concept analysis. AJN, American Journal of Nursing, 121(12), 30–38. https://doi.org/10.1097/01.naj.0000803188.10432.e1
Collins, B. L., & Saylor, J. (2018). The affordable care act. Nursing Management, 49(8), 42–48. https://doi.org/10.1097/01.numa.0000538917.37912.d4
Hospital Readmissions Reduction Program (HRRP). (2020, December 31). Centers for Medicare & Medicaid Services (CMS). Retrieved May 6, 2022, from https://www.hhs.gov/guidance/document/hospital-readmissions-reduction-program-0
Jack, K., Ridley, C., & Turner, S. (2019). Effective communication with older people. Nursing Older People, 31(4), 40–48. https://doi.org/10.7748/nop.2019.e1126
Johnson, B. H. (2016). Promoting patient- and family-centered care through personal stories. Academic Medicine, 91(3), 297–300. https://doi.org/10.1097/acm.0000000000001086
McFarlan, S., O’Brien, D., & Simmons, E. (2019). Nurse-leader collaborative improvement project: Improving patient experience in the emergency department. Journal of Emergency Nursing, 45(2), 137–143. https://doi.org/10.1016/j.jen.2018.11.007
Nibert, A., Myers, K. K., & Toms, R. (2020). Nurses’ Active Empathetic Listening Behaviors from the Voice of the Patient. Nursing Economic, 38(5), 267. https://www.proquest.com/docview/2452331338 parentSessionId=a4yGbxVCAA0d3AV1jb4mU4GPm6ROUzkvM9fdFzZ1MOw %3D&pq-origsite=summon&accountid=27965
Olaussen, A., Bade-Boon, J., Fitzgerald, M. C., & Mitra, B. (2018). Management of injured patients who were Jehovah’s witnesses, where blood transfusion may not be an option: A retrospective review. Vox Sanguinis, 113(3), 283–289. https://doi.org/10.1111/vox.12637
Rahmani, A., Vahedian-Azimi, A., Sirati-Nir, M., Norouzadeh, R., Rozdar, H., & Sahebkar, A. (2020). The effect of the teach-back method on knowledge, performance, readmission, and quality of life in heart failure patients. Cardiology Research and Practice, 2020, 1– 13. https://doi.org/10.1155/2020/8897881
Yoder, L. (2017). Care Coordination and Transition Management: Critical Roles for Medical-Surgical Nurses. Medsurg Nursing, 26(4), 225–228. https://www.proquest.com/docview/1929674089? parentSessionId=MHFk9fsiQFcn4Ldw66XHrP8Ca3lcRDXJqrzGDB6HqSo%3D&pq- origsite=summon&accountid=27965
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Question 
Develop a care coordination project plan for a population that is in need of care from multiple organizations.
Then, develop 10–12 slides for use in presenting your plan to administrative decision makers.