QUESTION
Care Coordination
4-5 pages APA ,3-5 scholarly references within the past 5 years.
Outline effective strategies for collaborating with patients and their families to achieve desired health outcomes.
◦Provide, for example, drug-specific educational interventions, 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 the provision of 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 health care 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.
◦Fine tune the presentation to your audience.
◦Stay focused on key issues of import with respect to the effects of resources, ethics, and policy on the provision of high-quality, patient-centered care.
◦Adhere to presentation best practices.
Assessment 3 Instructions: Care Coordination Presentation to Colleagues
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 in length, and record a video of your presentation.
Nurses have a powerful role in the coordination and continuum of care. All nurses must be cognizant of 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 provides an opportunity for 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.
Demonstration of Proficiency
By successfully 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 family to achieve desired outcomes.
◦Outline effective strategies for collaborating with 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 the provision of 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 health care policies affect patient-centered care.
◦Identify the potential impact of specific health care 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. Script and reference list are not submitted.
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 key factors nurses must consider to effectively participate in the care coordination process.
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.
Recording Equipment Setup and Testing
Check that your recording equipment and software are working properly 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 courseroom.
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 the coordination of care. To prepare, develop a detailed narrative script. The script will be submitted along with the video.
Presentation Format and Length
Create a detailed narrative script for your video presentation, approximately 4–5 pages in length. 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 presentation. 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 be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.
- Outline effective strategies for collaborating with patients and their families to achieve desired health outcomes.
◦Provide, for example, drug-specific educational interventions, 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 the provision of 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 health care 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 import with respect to 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 be sure that both assessment deliverables are included.
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| Subject | Nursing | Pages | 10 | Style | APA |
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Answer
Care Coordination
The Agency for Healthcare Research and Quality (AHRQ) describe care coordination as the deliberate organization of the patient-care activities and information sharing among the concerned individuals in the individual’s health. This is aimed at achieving effective and safer care. The patients’ preferences and needs should be established and communicated to the right stakeholders to achieve care coordination objectives. This fosters appropriate, effective, and safe care. According to Scholz and Minaudi (2015), care coordination further entails marshaling all the necessary resources, including humans, to conduct patient-care activities. Core elements that define care coordination include continuum, ethics, integrated care, and case management. This paper evaluates care coordination, including effective collaboration strategies with families and patients, and establishing the change management aspects.
Effective strategies for collaborating with the patient
Collaboration with patients and their families to provide quality and safe care is essential. Menear et al. (2020) espouse that Collaborative Mental Health Care (CMHC) conceptualizations comprise families and patients as central partners. One strategy to engage the patient and family in care planning and delivery is the behavior change technique (BCT). This approach is effective in engaging the family and patient to alter one’s thought and behavioral processes. As described by Goodridge et al. (2018), the framework entails several categories, including setting goals and plans, monitoring and feedback, social support, shaping knowledge, comparing behavior, associations, substitution and repetition, comparing the outcomes, and providing rewards.
Central to the BCT framework is communication and engaging the patient and family throughout the care processes. In setting goals and plans, for instance, Goodridge et al. (2018) outline the importance of identifying the barriers to effective care and developing long and short-term plans to address these barriers. Both the patient and the family provide feedback regarding the care and monitor for improvements. Social support, especially in chronic care conditions, involves the individual’s support to implement the care plan. The family members, for instance, play an important role in reminding the patient to take the medication and ensuring the individual is living a healthy lifestyle. It is essential to provide a social stimulus to cue or promote one’s behavior in the associations' category.
Change Management Aspects
According to the institute of medicine (IOM), patient-centered care involves acknowledging, providing information, and involving the patients in their care. However, the care approach should be respectful and responsive to the individual’s values, preferences, and needs. This is aimed at ensuring that the patient values the clinical decisions. During change management, the nursing theories guide the process, such as Kurt Lewin’s three-step model. In this approach, the stages include unfreezing, change, and refreezing (Wojciechowski et al., 2016). The direct impact on the individual’s experience, ensuring high quality, and patient-centered care is based on information sharing and failure to include the individual in the change implementation.
Lewin’s change theory first involves the unfreezing stage, characterized by creating the problem awareness, eliminating the old patterns, and demonstrating problems and issues. In patient care, it involves establishing the individual’s values, needs, and preferences. Failure to engage the patient results in limited information about the change and its importance. This causes resistance and limited commitment to implementing the developed change. Patient-centered care is further defined by raising the individual’s awareness regarding the change process and integrating the culture change. The success should be celebrated in the third stage, and the key performance indicators (KPIs) monitored. Failure to celebrate the patient’s success and ensure awareness limits the achievement of the change objectives.
Coordinated Care Plans Based on Ethical Decision Making
Ethics in care coordination entails the principles of justice, autonomy, fair, privacy, and confidentiality. Tonnessen, Ursin, and Brinchmann (2017) note that healthcare providers should ensure fair access to quality and safe care. In addition, there should be transparency in the decision-making process. In implementing the care coordination strategy, such as the BCT, transparency involves providing accurate information to the patient regarding the care process and the outcomes. The principle of justice in decision making is reflected in ensuring all individuals access equal and quality care while respecting their values and rights.
The individual’s privacy and confidentiality in the decision-making process should also be considered. The underlying assumption is that the patient may not appreciate their information being shared with unauthorized individuals. In mental healthcare and attending to geriatrics, ensuring their privacy and confidentiality is central in fostering their engagement in implementing the care plan. Another core principle is autonomy, which entails the individual’s freedom in the decision making process. Therefore, healthcare providers should provide the patient with sufficient information regarding the healthcare condition and potential care plans and assist the individual in making decisions. The healthcare providers, including nurses and physicians should collaborate and make informed decisions while considering the patient’s preferences.
Impacts of Health Care Policy on Patient Experience and Outcomes
Several healthcare policies contribute to patient outcomes and quality services. The Affordable Care Act of 2010, for instance, involves insurance coverage to all individuals. Although the Act has recently faced several challenges under Trump’s administration, it provides the healthcare providers with the chance to shape and participate in delivering quality healthcare services. The Patient Safety and Quality Improvement Act of 2005 ensures the protection of healthcare workers in unsafe areas. This policy encourages accountability to medical errors and promoting the patients’ confidentiality and privacy rights. This is achieved by fines for individuals that breach the patient’s rights.
Healthcare policies are developed in the interest of various stakeholders, from patients to healthcare providers. According to Birk (2016), these policies protect the individuals’ rights and ensure the delivery of safe and quality healthcare services. They are also aimed at ensuring adequate support to improve healthcare service delivery. This is achieved through procuring more facilities and infrastructure. Healthcare providers are trained to provide quality care. On the other hand, the policies protect the patients’ welfare through ensuring accountability among the healthcare providers in case of any issues, such as errors in healthcare delivery. However, the policies are subject to continuous review for improvements.
Nurses’ Role in Coordination and Continuum of Care
Registered nurses (RNs) play a crucial role in the care continuum. Notably, cost control and quality enhancement depend on profound coordination of the individual’s care. Efficiencies in healthcare delivery are achieved by coordinating care while acknowledging the patients’ and families' preferences and needs. Registered nurses contribute to the care continuum by collaborating with other partners and using their skills to enhance care for various patients (Xu et al., 2020). Their education, competencies, and experience determine the care coordination role's aptitude in various settings, including home care, schools, and ambulatory. The nurses’ skills, essential in care coordination, include teamwork, communication, and critical thinking to make informed decisions.
Registered nurses’ competencies in counseling, working with patients and their families, and decision-making significantly contribute to care coordination and to provide quality and safe care to patients according to their needs and preferences. The inter-professional plan of care involves every individual contributing their knowledge in making informed decisions for the patients. In contemporary healthcare service delivery, registered nurses use technology to support care coordination through communication, referrals, and engaging with patients. Continuum in care and coordination are further achieved through continuous research to establish evidence-based practices (EBPs) for patient care.
Conclusion
Care coordination remains a vital aspect of ensuring quality and safe patient care. AHRQ defines care coordination as organizing the patient-care activities and sharing information among various stakeholders from the individual’s family to the healthcare providers to provide adequate care. In care coordination, it is centered on acknowledging the patient’s values and preferences and factoring them in the care delivery. Registered nurses are key players in care coordination and ensuring a continuum in quality care delivery.
References
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Birk, H. S. (2016). United States National Healthcare Policies 2015: An analysis with implications for the future of medicine. Cureus, 8(1). Goodridge, D., Henry, C., Watson, E., McDonald, M., New, L., Harrison, E. L., ... & Rotter, T. (2018). Structured approaches to promote patient and family engagement in treatment in acute care hospital settings: protocol for a systematic scoping review. Systematic reviews, 7(1), 35. Menear, M., Dugas, M., Careau, E., Chouinard, M. C., Dogba, M. J., Gagnon, M. P., ... & Knowles, S. (2020). Strategies for engaging patients and families in collaborative care programs for depression and anxiety disorders: A systematic review. Journal of affective disorders, 263, 528-539. Scholz, J., & Minaudo, J. (2015). Registered nurse care coordination: Creating a preferred future for older adults with multimorbidity. OJIN: The Online Journal of Issues in Nursing, 20(3). 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. Wojciechowski, E., Pearsall, T., Murphy, P., & French, E. (2016). A case review: Integrating Lewin’s theory with lean’s system approach for change. Online Journal of Issues in Nursing, 21(2). Xu, D. R., Dev, R., Shrestha, A., Zhang, L., Shrestha, A., Shakya, P., ... & Karmacharya, B. M. (2020). Nurse-led Continuum of care for people with Diabetes and prediabetes (NUCOD) in Nepal: study protocol for a cluster randomized controlled trial. Trials, 21(1), 1-12. |