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NURS FPX 4050 Assessment 3 Care Coordination Presentation to Colleagues

NURS FPX 4050 Assessment 3 Care Coordination Presentation to Colleagues

Care Coordination Presentation to Colleagues

Good morning everyone. Today we are here to one of the most important aspects of health care services, which is coordinated care essential to transforming the way we provide care to increase the quality of care, health care access, improve communication between colleagues, patients, their families, and other stakeholders (Peterson et al., 2019). Coordinated care can be termed care coordination. Please consider the terms interchangeable during this presentation. 

Before we jump to the content of the presentation, it is important to understand what the term care coordination actually means. One definition from NEJM Catalyst defines care coordination as “delivery of patients’ health care from different providers, specialists, and stakeholders by aiming to improve health care outcomes, patient outcomes, and health care professionals’ outcome along with reducing cost and limiting redundant procedures and practices (NEJM Catalyst, 2021).” 

Let’s look at some examples to understand this. 

In a relay race, athletes pass the baton to other athletes, and as soon as the baton is passed their job is over. Even though it is coordinated and synchronous, it does not represent complete coordinated care. In health care, nurses, pharmacists, physicians, and other specialists communicate back and forth to assess disease and then find the treatment plan. Thus, care coordination is not just a one-way process as it also includes back-and-forth communication (Weaver & Jacobsen, 2018).

Now, let’s look at the other side. 

It is interesting to see that such an approach can lead to lower-quality care at times as there will be redundant procedures. For example, sending patients to ED when the ED health care providers clearly communicated to other professionals about the patient not requiring ED care. Another example is asking the patient about his or her medical history when the information is already taken and stored in EHRs (Marsden et al., 2018). 

Another example is failing to communicate with patients and families to understand allergies, medical history, cultural and spiritual needs, and other care aspects to provide patient-centered care will result in adverse events such as reactions, mortality, and morbidity. This creates a need to outline and adopt effective strategies with patients and families to provide high-quality care (Lynch et al., 2018). 

Outlining effective strategies for collaborating with patients and their families is based on patient-centered, culture-based, and evidence-based holistic care approaches. The strategies are

  • Nurse-led multidisciplinary care initiative where nurses are the center of the process, communication, and decision-making (Marsden et al., 2018).
  • Empowering patients and families by including them in discussions, decision-making, and treatment through consent (Sefcik et al., 2018).
  • Providing support in different languages, culture-based holistic care, and showing respect and empathy to establish a better patient-nurse-physician relationship (Song et al., 2017). 
  • Adopting a shared decision-making model along with knowledge sharing with colleagues and peers to make informed decisions (Bunn et al., 2018).
  • Using direct communication-based and avoiding in-direct communication. For example, direct communication during diagnosis is effective and in-direct communication may lead to conflicts (Garry et al., 2020). 
  • Using assertive communication during discussions and decision-making whereas persuasive communication promotes better decision-making during treatment selection (Omura et al., 2018).
  • Engaging patients at the system, individual and organizational levels helps in better coordination between nurses, patients, physicians, and other stakeholders as everyone is involved in direct communication, discussion, and decision-making (Clay & Parsh, 2016).  
  • Limited use of messaging applications and increased use of discussions, reporting systems such as error reporting, and medication prescribing, dispensing, and administration increases patient safety (Hefner et al., 2019).
  • Using the EBP model to implement change and evaluate outcomes as a unit to increase coordination between HCPs to increase communication and knowledge-sharing (Menear et al., 2016). 
  • Implementing root-cause analysis and conflict management in reducing issues and effectively managing colleagues (Grubaugh & Flynn, 2018).
  • Supporting peers and educating them to provide emotional, spiritual, academic, and holistic support is critical as it leads to a safer environment for practice. This promotes health literacy (Ofei & Paarima, 2021). 
  • Reporting errors promptly and following government and hospital policies to show high transparency and responsibility (Clay & Parsh, 2016). 

Now, it is important to identify aspects of change management that directly affect quality care and patient experience as it defines and controls how strategies are implemented and their outcomes. 

The first aspect that affects the change management and quality of care is the EBP model that will be used to implement the change and evaluate the outcome of the strategies. Using models such as Iowa EBP, ACE (Academic Center for Evidence-Based Practice), Johns Hopkins Nursing Evidence-Based Practice Model, and Lewin’s model of change aid in implementing the strategies, evaluating the outcome, and changing or updating the strategy. 

The second aspect is leadership, which is critical in motivating and empowering nurses and HCPs to adopt care coordination strategies as it affects the way nurses perceive the strategies and how effective the communication and collaboration between the interdisciplinary and multidisciplinary teams are (Song et al., 2017). The third aspect is the economic model used along with resources provided to implement the strategies as changes require funds and resources to successfully implement the strategies (Peterson et al., 2019). The fourth aspect is the training and competency levels of nurses and HCPs as the higher the competencies in culture-based care, patient-centered approach, nurse-patient relationship, safety and security of patients, and patient’s family management, the better will be the outcome (Sefcik et al., 2018). 

The fifth aspect is providing care in different languages as communities include patients from different cultures. Failing to provide support in different languages will reduce patient satisfaction and patients will find it difficult to increase their health literacy. The sixth aspect is the nurse-to-patient ratio the lower the ratio, the higher will be the burnout and chances of errors. Errors such as medication errors, administration errors, and record errors will reduce the quality of care and reduce the reputation of healthcare facilities.  

Ethical decision-making is an important aspect of any decision-making as it highlights the possible implications of the decision. 

The coordinated care plan is based on ethical decision-making as it addresses the core ethical components such as justice, fairness, equity, responsibility, honesty, trust, openness, and respect, and transparency. The component of justice is addressed by the use of patient-centered and culture-based care where each patient is treated based on the characteristics and individual aspects (Omura et al., 2018). The component of fairness is addressed by direct communication where all the patients were treated with compassion, inclusiveness, and support. The implication is it increases quality care and patient satisfaction (Grubaugh & Flynn, 2018). 

Equity is an important aspect of the coordinated care plan as cost-effective care is a major part of the plan where everyone has equal access to health care and its services and is treated equally but based on individual needs such as cultural needs (Ofei & Paarima, 2021). Also, the aspect of patient empowerment, consent, and involvement of families highlights ethical decision-making. The implication is it increases the trust of the community in health care services and also, it empowers patients (Garry et al., 2020). Further, the plan advocates for openly and honestly disclosing any errors to the patient and also provide any needed information regarding the health condition through education (Hefner et al., 2019). Thus, it represents an ethical aspect of transparency as well. The implication is it increases satisfaction levels and high-quality care. 

Even though the plan looks good, but it is based on four assumptions. They are: everyone in the organization including patients, community, and families will accept the change and follow the coordinated plan (Menear et al., 2016); the funding and resources needed will be provided to successfully implement the change; all the ethical aspects will be followed; and the plan will be effective and can be implemented without any resistance or a limited number of challenges or obstacles (Marsden et al., 2018).  

When it comes to the potential impact of specific health care policies and provisions such as the affordable care act, HIPPA act, effective treatments through preventive care, and other policies affect the plan.

The ACA Act provides key provisions such as cost-effective care, emphasizing prevention, effective treatments, quality improvement, and easy access to health care. These provisions affect the care plan they complement each other as both the provisions and plan aim to provide high-quality care with cost-effective treatments (Brooks et al., 2017). Cost-effective care increases patient satisfaction and a better nurse-to-patient ratio reduces burnout in nurses. From this, it can be logically concluded that provisions positively impact the coordination plan (Chu et al., 2020). 

NURS FPX 4050 Assessment 3 Care Coordination Presentation to Colleagues

Further, quality improvement provisions aid in implementing high-quality patient-centered care, preventive measurement, and disease management (Edmonds et al., 2016). From this, it can be concluded that preventive measure provisions reduce disease rates. Also, the HIPPA act and insurance claims and fraud prevention promote better documentation, EHRs, and safety of patient information to increase better insurance claim outcomes and data protection (Shaw et al., 2014). One negative impact it might have based on logical analysis is that it is difficult to provide high-quality care with a high nurse-to-patient ratio at an affordable cost as Medicaid does not fully cover all the conditions, treatment plans, and medicine (Chu et al., 2020). Considering everything, it is clear that nurses like you and me are the central aspect of health care services where we act as not only nurses but also as policy-makers, decision-makers, educators, advocators, care providers, responsible and ethically sound professionals, leaders, as well as coordinators. Thus, we are the central part of health care services in many ways and our contribution together can transform the way coordinated care is provided. 


Brooks, G., Hoverman, J., & Colla, C. (2017). The affordable care act and cancer care delivery. The Cancer Journal23(3), 163-167. https://doi.org/10.1097/ppo.0000000000000259

Bunn, F., Goodman, C., Russell, B., Wilson, P., Manthorpe, J., & Rait, G. et al. (2018). Supporting shared decision making for older people with multiple health and social care needs: a realist synthesis. BMC Geriatrics18(1). https://doi.org/10.1186/s12877-018-0853-9

Chu, Q., Li, T., Hsieh, M., Yi, Y., Gibbs, J., Lyons, J., & Wu, X. (2020). The positive impact of the Patient Protection and Affordable Care Act Medicaid expansion on Louisiana women with breast cancer. Cancer127(5), 688-699. https://doi.org/10.1002/cncr.33265

Clay, A., & Parsh,, B. (2016). Patient- and family-centered care: it’s not just for pediatrics anymore. AMA Journal Of Ethics18(1), 40-44. https://doi.org/10.1001/journalofethics.2016.18.1.medu3-1601

Edmonds, J., Campbell, L., & Gilder, R. (2016). Public health nursing practice in the affordable care act era: a national survey. Public Health Nursing34(1), 50-58. https://doi.org/10.1111/phn.12286

Garry, K., Blecker, S., Saag, H., Szerencsy, A., Jones, S., Testa, P., & Kang, S. (2020). Patient experience with notification of radiology results: a comparison of direct communication and patient portal use. Journal Of The American College Of Radiology17(9), 1130-1138. https://doi.org/10.1016/j.jacr.2020.01.046

Grubaugh, M., & Flynn, L. (2018). Relationships among nurse manager leadership skills, conflict management, and unit teamwork. JONA: The Journal Of Nursing Administration48(7/8), 383-388. https://doi.org/10.1097/nna.0000000000000633

Hefner, J., MacEwan, S., Biltz, A., & Sieck, C. (2019). Patient portal messaging for care coordination: a qualitative study of perspectives of experienced users with chronic conditions. BMC Family Practice20(1). https://doi.org/10.1186/s12875-019-0948-1

NURS FPX 4050 Assessment 3 Care Coordination Presentation to Colleagues

Lynch, S., Witt, W., Ali, M., Teich, J., Mutter, R., Gibbons, B., & Walsh, C. (2018). Care coordination in emergency departments for children and adolescents with behavioral health conditions. Pediatric Emergency CarePublish Ahead of Print. https://doi.org/10.1097/pec.0000000000001545

Marsden, E., Craswell, A., Taylor, A., Coates, K., Crilly, J., & Broadbent, M. et al. (2018). Nurse-led multidisciplinary initiatives to improve outcomes and reduce hospital admissions for older adults: The Care coordination through Emergency Department, Residential Aged Care, and Primary Health Collaboration project. Australasian Journal On Ageing37(2), 135-139. https://doi.org/10.1111/ajag.12526

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 Open6(9), e012949. https://doi.org/10.1136/bmjopen-2016-012949

NEJM Catalyst. (2021). What is care coordination?. Catalyst.nejm.org. Retrieved 4 July 2021, from https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0291.

Ofei, A., & Paarima, Y. (2021). Perception of nurse managers’ care coordination practices among nurses at the unit level. International Journal Of Care Coordination24(1), 17-27. https://doi.org/10.1177/2053434521999978

Omura, M., Stone, T., Maguire, J., & Levett-Jones, T. (2018). Exploring Japanese nurses’ perceptions of the relevance and use of assertive communication in healthcare: A qualitative study informed by the Theory of Planned Behaviour. Nurse Education Today67, 100-107. https://doi.org/10.1016/j.nedt.2018.05.004

NURS FPX 4050 Assessment 3 Care Coordination Presentation to Colleagues

Peterson, K., Anderson, J., Bourne, D., Charns, M., Gorin, S., & Hynes, D. et al. (2019). Health care coordination theoretical frameworks: a systematic scoping review to increase their understanding and use in practice. Journal Of General Internal Medicine34(S1), 90-98. https://doi.org/10.1007/s11606-019-04966-z

Sefcik, J., Petrovsky, D., Streur, M., Toles, M., O’Connor, M., & Ulrich, C. et al. (2018). “In Our Corner”: a qualitative descriptive study of patient engagement in a community-based care coordination program. Clinical Nursing Research27(3), 258-277. https://doi.org/10.1177/1054773816685746

Shaw, F., Asomugha, C., Conway, P., & Rein, A. (2014). The patient protection and affordable care act: opportunities for Prevention and public health. The Lancet384(9937), 75-82. https://doi.org/10.1016/s0140-6736(14)60259-2

Song, H., Ryan, M., Tendulkar, S., Fisher, J., Martin, J., & Peters, A. et al. (2017). Team dynamics, clinical work satisfaction, and patient care coordination between primary care providers. Health Care Management Review42(1), 28-41. https://doi.org/10.1097/hmr.0000000000000091

Weaver, S., & Jacobsen, P. (2018). Cancer care coordination: opportunities for healthcare delivery research. Translational Behavioral Medicine8(3), 503-508. https://doi.org/10.1093/tbm/ibx079

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