Care Coordination Presentation to Colleagues assessment 3

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Care Coordination Presentation to Colleagues assessment 3

Care Coordination Presentation to Colleagues assessment 3

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NURS FPX 4050 Assessment 3 Care Coordination Presentation to Colleagues 1

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Care Coordination Presentation to Colleagues Capella University NURS FXP-4050 Coordinating Patient-Centered Care Gloria Barrera May, 31,

Care Coordination Presentation to Colleagues Hello everyone. My name is Carine; I work as a registered nurse and am currently the director of nursing at SunnyCrest. I have been a registered nurse for eight years with experience in different departments of hospital and nursing home settings. I have worked in the ICU, med Surg, and ER units and then decided to try long-term care settings. Three months ago, I was made director of nursing, where I had the opportunity to manage and coordinate resident/patient- centered care. I want to welcome you to the Care Coordination Presentation officially. The presentation will focus on the roles of registered nurses in care coordination, and the activities nurses are supposed to work on to ensure the adoption of effective care coordination processes in a health facility. The presentation will also touch on factors that affect the efficiency of nurses in providing care coordination to their patients. Care Coordination To begin, we are going to define what care coordination is. Care coordination is defined as the deliberate and intentional organization of patient care services and sharing of patient- relevant data and information in health setups by all individuals responsible for the patient’s health (Hannigan et al., 2018). Care coordination has been used for decades and, as such, has been incorporated by different organizations dealing with patient care and medical professions. Through care coordination, patients receive quality, safe and effective care from those charged with their care. In order to achieve this, care coordination always focuses on promoting teamwork efficiently and cost-effectively to improve health outcomes for clients. Through care coordination, the patient’s needs are of the highest priority, and every individual caring for them is required to have information about their needs before interacting with the patient. This enables

ensures that the transition of care from one facility or professional to another is seamless. It also allows patients to add their decisions and inputs to their care process. Communication as such is essential in ensuring there is a continuum of care. The third focuses on the patient’s overall health, not just physical health. Care coordination should involve the assessment of the patient`s needs (Sturgiss et al., 2022). Many patients suffer from psychological, spiritual, and emotional problems due to their physical health. It is the role of the nurse to assess the patient and determine the appropriate care needed. This is accomplished with an assessment followed by referral to different specialists and is part of care coordination between medical professionals. Lastly, communication is a critical element of care coordination; therefore, it must be used appropriately. Care coordination is effective if the communication between medical professionals and health service providers is done clearly (Sturgiss et al., 2022). This would enable understanding of the information. Communication with patients should be done clearly to understand the communicated message. This is essential in allowing them to voice their input in the care coordination process. Strategies for Collaborating with Patients and Families Patient care requires collaboration between the attending medical professional and patients and their families. Collaboration between these groups of people in inpatient care ensures that the patient experiences and needs are met. Due to different cultural backgrounds, patients’ families may have a say in the patient’s care. This is common in communities with tightly knit family setups and patients whose care is reliant on the decisions of their families. As the primary caregivers, Registered Nurses have the longest interaction time with patients. This means that registered nurses are expected to ensure there is a collaboration between them and

their patients. This collaboration requires the adoption of patient-based collaboration strategies by the assigned registered nurses. The first collaboration strategy that should be adopted is the inclusion of patients in their care plan. Patients must have a say in their care (Menear et al., 2022). By incorporating their decisions and addressing their fears and questions, registered nurses promote a collaborative spirit that builds on the nurse-patient relationship. Patients involved in their care plan and care coordination are known to recover faster and benefit from the care coordination and care planning. Additionally, the inclusion of patients allows for openness during treatment, ensuring proper diagnosis. This is enabled through appropriate communication between the nurse and patient. The second collaboration strategy that nurses should adopt is proper communication. In care coordination, nurses must communicate directly and clearly to patients and their families (Menear et al., 2016). Nurses can determine the care patients and their families need through proper communication. Additionally, adequate contact with other professionals ensures nurses can coordinate the care of patients seamlessly. Good communication allows for instructions and messages to be shared with other medical staff, and the letters can be understood for proper care to occur. Also, adequate contact with the patient and family is necessary for any consideration to be given. Informed consent relies heavily on appropriate communication and approval by the patient or family. Change Management Aspects Affecting Patient-Centered Care In the care of patients, nurses can advocate for changes in factors and environments surrounding the patient. These changes may positively or negatively affect the patient. Changes in an individual’s life are bound to happen, especially when they are patients. Through evolution,

patient should receive the same treatment as others about being offered medical services (Ilkafah et al., 2021). Lastly, beneficence and non-maleficence dictate that nurses should not harm the patient (Ilkafah et al., 2021). This can be expressed through referral to other health care services through care coordination to ensure the patient receives the best care and harm to their health is reduced. Impact of specific health care policy provisions The government is a significant stakeholder in the healthcare industry. To ensure that patients receive the best possible care, governments place regulations and laws to dictate aspects of patient care. The two significant government policies that affect care coordination in health facilities include the Affordable Care Act (ACA) and the Health Insurance Portability and Accountability Act (HIPAA). We will focus on the ACA as it has notable effects on patient care and care coordination. The ACA was enacted to ensure that patients receive finances for their treatments through insurance covers. The Act has enabled easy access to healthcare services and improved health quality and outcomes for patients. Through the ACA, there is reduced spending on patient care. The care coordination aspect affected by the ACA is the coordination of care between different service providers from other healthcare delivery systems, which is beneficial for low-income patients (Chen et al., 2018). This creates an opportunity for the reduction of medical errors and unnecessary services. The ACA achieves these reductions by coordinating discharges from one health care setup to another. Registered nurses play an essential role in ensuring that patients are cared for in the best possible way. This can be achieved through care coordination which the primary caregivers effectively do. Registered nurses should consider the various elements and principles of ethics to

ensure care coordination impacts patients’ lives. Nurses should acknowledge that change models help improve patient care, which is the primary role of care coordination. Thank you.

Sturgiss, E., Peart, A., Richard, L., Ball, L., Hunik, L., & Chai, T. et al. (2022). Who is at the center of what? A scoping review of the conceptualization of ‘centredness’ in healthcare. BMJ Open , 12 (5), e059400. doi/10.1136/bmjopen-2021-
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Care Coordination Presentation to Colleagues
Capella University
NURS FXP-4050 Coordinating Patient-Centered Care
Gloria Barrera
May, 31,2022
2
Care Coordination Presentation to Colleagues
Hello everyone. My name is Carine; I work as a registered nurse and am currently the
director of nursing at SunnyCrest. I have been a registered nurse for eight years with experience
in different departments of hospital and nursing home settings. I have worked in the ICU, med
Surg, and ER units and then decided to try long-term care settings. Three months ago, I was
made director of nursing, where I had the opportunity to manage and coordinate resident/patient-
centered care. I want to welcome you to the Care Coordination Presentation officially. The
presentation will focus on the roles of registered nurses in care coordination, and the activities
nurses are supposed to work on to ensure the adoption of effective care coordination processes in
a health facility. The presentation will also touch on factors that affect the efficiency of nurses in
providing care coordination to their patients.
Care Coordination
To begin, we are going to define what care coordination is. Care coordination is defined
as the deliberate and intentional organization of patient care services and sharing of patient-
relevant data and information in health setups by all individuals responsible for the patient’s
health (Hannigan et al., 2018). Care coordination has been used for decades and, as such, has
been incorporated by different organizations dealing with patient care and medical professions.
Through care coordination, patients receive quality, safe and effective care from those charged
with their care. In order to achieve this, care coordination always focuses on promoting
teamwork efficiently and cost-effectively to improve health outcomes for clients. Through care
coordination, the patient’s needs are of the highest priority, and every individual caring for them
is required to have information about their needs before interacting with the patient. This enables
3
seamless transitions between one medical professional to another and increases the efficiency
with which the planning of care and activities of maintenance is done.
As nurses charged with caring for patients, care coordination involves several activities
that you perform daily. However, these activities may be random or follow a specific procedure
set by the facilities. In care coordination, these activities are streamlined and conducted to ensure
that different patient care aspects meet certain criteria and achieve a specific goal. Through care
coordination, the delivery of patient healthcare needs and services is synchronized with various
healthcare providers and specialists. Through synchronization, patients can receive care from
other providers that are in tandem with the care plan for the patient. Care coordination allows for
resource-saving by both the patient and the facility. This is done by eliminating tests that are not
needed and ensuring that readmission of patients is kept at a minimum. This aspect of care
coordination is made possible through four main elements of care coordination.
Elements of Care Coordination
Care coordination is made possible through four main elements that ensure both patients
and the medical staff feel its benefits. The first element of care coordination is the ease of access
to medical services and providers (Izumi et al., 2018). This is an essential and critical element in
care coordination. Patients usually need access to several benefits and providers necessary for
their care. This aspect involves various factors such as the patient’s flexibility in making
appointments, off-hours services to the patient, short waiting times for meetings, timely
appointments, and electronic methods such as telehealth services.
The second element is good communication. This involves appropriate and timely
communication between different healthcare providers in the care of the patients (Sturgiss et al.,
2022). It also consists in incorporating the patient in touch with other medical professionals. This
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4
ensures that the transition of care from one facility or professional to another is seamless. It also
allows patients to add their decisions and inputs to their care process. Communication as such is
essential in ensuring there is a continuum of care.
The third focuses on the patient’s overall health, not just physical health. Care
coordination should involve the assessment of the patient`s needs (Sturgiss et al., 2022). Many
patients suffer from psychological, spiritual, and emotional problems due to their physical health.
It is the role of the nurse to assess the patient and determine the appropriate care needed. This is
accomplished with an assessment followed by referral to different specialists and is part of care
coordination between medical professionals.
Lastly, communication is a critical element of care coordination; therefore, it must be
used appropriately. Care coordination is effective if the communication between medical
professionals and health service providers is done clearly (Sturgiss et al., 2022). This would
enable understanding of the information. Communication with patients should be done clearly to
understand the communicated message. This is essential in allowing them to voice their input in
the care coordination process.
Strategies for Collaborating with Patients and Families
Patient care requires collaboration between the attending medical professional and
patients and their families. Collaboration between these groups of people in inpatient care
ensures that the patient experiences and needs are met. Due to different cultural backgrounds,
patients’ families may have a say in the patient’s care. This is common in communities with
tightly knit family setups and patients whose care is reliant on the decisions of their families. As
the primary caregivers, Registered Nurses have the longest interaction time with patients. This
means that registered nurses are expected to ensure there is a collaboration between them and
5
their patients. This collaboration requires the adoption of patient-based collaboration strategies
by the assigned registered nurses.
The first collaboration strategy that should be adopted is the inclusion of patients in their
care plan. Patients must have a say in their care (Menear et al., 2022). By incorporating their
decisions and addressing their fears and questions, registered nurses promote a collaborative
spirit that builds on the nurse-patient relationship. Patients involved in their care plan and care
coordination are known to recover faster and benefit from the care coordination and care
planning. Additionally, the inclusion of patients allows for openness during treatment, ensuring
proper diagnosis. This is enabled through appropriate communication between the nurse and
patient.
The second collaboration strategy that nurses should adopt is proper communication. In
care coordination, nurses must communicate directly and clearly to patients and their families
(Menear et al., 2016). Nurses can determine the care patients and their families need through
proper communication. Additionally, adequate contact with other professionals ensures nurses
can coordinate the care of patients seamlessly. Good communication allows for instructions and
messages to be shared with other medical staff, and the letters can be understood for proper care
to occur. Also, adequate contact with the patient and family is necessary for any consideration to
be given. Informed consent relies heavily on appropriate communication and approval by the
patient or family.
Change Management Aspects Affecting Patient-Centered Care
In the care of patients, nurses can advocate for changes in factors and environments
surrounding the patient. These changes may positively or negatively affect the patient. Changes
in an individual’s life are bound to happen, especially when they are patients. Through evolution,
6
patients experience appropriate care, and health improvements are noted. One change theory that
is beneficial and can be adopted by nurses in the care of patients is the three-stage model of
change.
The three-stage model of change developed by Kurt Lewin has three stages, namely
unfreezing, changing, and refreezing (Burnes, 2019). In care coordination that is patient-
centered, registered nurses must assess the conditions surrounding the patient. This is the process
of unfreezing. The nurse must also determine the requirements necessary to change the patients’
needs. This is followed by switching, which involves changing the patient’s conditions. In this
stage, registered nurses implement changes determined in the first stage. The last step is
refreezing, where the nurse finalizes the changing process. Here, the nurse allows the changes to
be adopted and institutionalized. This model would be beneficial to registered nurses and health
care facilities as it incorporates three stages geared to assessing conditions, changing the states,
and institutionalizing the changes made.
Coordinating Care Plans and Ethical Decision Making
The nurses’ code of ethics provides guidelines on how nurses are expected to act in their
professional capacity as primary caregivers. These are the guidelines that define a nurse. All
nurses undergo lessons on ethics to enable them to navigate the field of caregiving without facing
ethical issues involving their conduct and decisions. In coordinating care for patients, nurses
should adhere to the four main principles of ethics: non-maleficence, justice, autonomy, and
beneficence.
When coordinating the care of patients, nurses should allow patients to make their
decisions regarding the care they are to receive. This aligns with the principle of autonomy
(Ilkafah et al., 2021). Additionally, justice should influence care coordination such that each
7
patient should receive the same treatment as others about being offered medical services (Ilkafah
et al., 2021). Lastly, beneficence and non-maleficence dictate that nurses should not harm the
patient (Ilkafah et al., 2021). This can be expressed through referral to other health care services
through care coordination to ensure the patient receives the best care and harm to their health is
reduced.
Impact of specific health care policy provisions
The government is a significant stakeholder in the healthcare industry. To ensure that
patients receive the best possible care, governments place regulations and laws to dictate aspects
of patient care. The two significant government policies that affect care coordination in health
facilities include the Affordable Care Act (ACA) and the Health Insurance Portability and
Accountability Act (HIPAA). We will focus on the ACA as it has notable effects on patient care
and care coordination.
The ACA was enacted to ensure that patients receive finances for their treatments through
insurance covers. The Act has enabled easy access to healthcare services and improved health
quality and outcomes for patients. Through the ACA, there is reduced spending on patient care.
The care coordination aspect affected by the ACA is the coordination of care between different
service providers from other healthcare delivery systems, which is beneficial for low-income
patients (Chen et al., 2018). This creates an opportunity for the reduction of medical errors and
unnecessary services. The ACA achieves these reductions by coordinating discharges from one
health care setup to another.
Registered nurses play an essential role in ensuring that patients are cared for in the best
possible way. This can be achieved through care coordination which the primary caregivers
effectively do. Registered nurses should consider the various elements and principles of ethics to
8
ensure care coordination impacts patients’ lives. Nurses should acknowledge that change models
help improve patient care, which is the primary role of care coordination. Thank you.
9
References
Burnes, B. (2019). The origins of Lewin’s three-step model of change. The Journal of Applied
Behavioral Science, 56(1), 32-59. https://doi.org/10.1177/0021886319892685
Chen, J., DuGoff, E., Novak, P., & Wang, M. (2018). Variation of hospital-based adoption of care
coordination services by community-level social determinants of health. Health Care
Management Review, 45(4), 332-341. https://doi.org/10.1097/hmr.0000000000000232
Hannigan, B., Simpson, A., Coffey, M., Barlow, S., & Jones, A. (2018). Care coordination as
imagined, care coordination as done: findings from a cross-national mental health
systems study. International Journal of Integrated Care, 18(3).
https://doi.org/10.5334/ijic.3978
Ilkafah, I., Mei Tyas, A., & Haryanto, J. (2021). Factors related to the implementation of nursing
care ethical principles in Indonesia. Journal of Public Health Research, 10(2),
jphr.2021.2211. https://doi.org/10.4081/jphr.2021.2211
Izumi, S., Barfield, P., Basin, B., Mood, L., Neunzert, C., & Tadesse, R. et al. (2018). Care
coordination: Identifying and connecting the most appropriate care to the
patients. Research in Nursing & Health, 41(1), 49-56. https://doi.org/10.1002/nur.21843
Menear, M., Dugas, M., Houle, J., Kates, N., Knowles, S., & Martin, N. et al. (2022). Strategies
for engaging patients and families in collaborative mental health care. International
Journal of Integrated Care, 22(S2), 157. https://doi.org/10.5334/ijic.icic21323
Menear, M., Gervais, M., Careau, E., Chouinard, M., Cloutier, G., & Delorme, A. et al. (2016).
Strategies and impacts of patient and family engagement in collaborative mental
healthcare: Protocol for a systematic and realist review. BMJ Open, 6(9), e012949.
https://doi.org/10.1136/bmjopen-2016-012949
10
Sturgiss, E., Peart, A., Richard, L., Ball, L., Hunik, L., & Chai, T. et al. (2022). Who is at the
center of what? A scoping review of the conceptualization of ‘centredness’ in
healthcare. BMJ Open, 12(5), e059400. https://doi.org/10.1136/bmjopen-2021-059400
Company

Care Coordination Presentation to Colleagues assessment 3