Care Coordination Presentation to Colleagues Essay

Care Coordination Presentation to Colleagues Essay

Care Coordination Presentation to Colleagues Essay

Hello everyone, welcome to the care coordination presentation; my name is (insert your name here). In this presentation, I shall focus on the essentials of care coordination, including strategies for collaborating with patients and their families to achieve the desired health outcomes, the aspect of change that directly affects elements of patient experience in the context of high-quality and patient-centered care delivery, the rationale for coordinating care plans based on ethical decision making, the potential impacts of health care policy provisions on outcomes and patient experiences, and the nurse’s role in care coordination and continuum. I hope this engagement will enhance your knowledge and awareness of elements of care coordination and strategies to coordinate care with patients and family members.

Overview of Care Coordination

Before delving into an in-depth discussion on the identified themes for this presentation, it is essential to define care coordination and underscore its components that render coordinated care necessary in enhancing care quality. The Agency for Healthcare Research and Quality [AHRQ] (2018) defines care coordination as the aspect or practice of “deliberately organizing patient care activities and sharing information among all the participants concerned with a patient’s care to achieve safer and more effective care.” In this sense, approaches to care coordination include case management, communicating to share information regarding patients’ needs, creating proactive care plans, developing and implementing monitoring and follow-up plans, teamwork, medication management, and linking patients to community resources (Agency for Healthcare Research and Quality, 2018). These elements enable healthcare professionals to partner with patients and family members, improve transitions, prevent adverse events, and implement individualized care plans.

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Strategies for Collaborating with Patients and Families

Often, healthcare professionals provide fragmented care to patient populations when effective interventions for addressing the current disjoints are insufficient. In the same breath, patients with life-threatening conditions like heart disease, chronic obstructive pulmonary disease (COPD), and cancer are susceptible to death, compromised quality of life, a high risk of readmissions, and the subsequent complications associated with chronic diseases when healthcare professionals provide fragmented care. According to Boulet et al. (2019), interdisciplinary and interprofessional collaboration in care delivery results in multiple benefits, including decreased mortality, improved transitions of care, and reduced readmission rates from diverse causes. Equally, involving patients and family members in healthcare processes through care coordination improves patient experiences, enhances self-management, and bolsters patients’ awareness of the prevailing conditions through education (Boulet et al., 2019, 76). Finally, collaborating with patients and families promotes the concept of shared decisions that improve patients’ autonomy in influencing care trajectories.

Although collaborating with patients and families has positive implications for care quality and health outcomes, it is essential to develop a contingency plan for facilitating teamwork, considering the challenges facing patients and families. For example, they grapple with poor health literacy, limited control over care processes, and a lack of awareness of self-management approaches. As a result, a plan for collaborating with patients and families includes the following priorities; patient education, improved communication, safeguarding patient autonomy, and influence in care processes or decisions. Firstly, educating patients and family members ensures effective dissemination of medical therapy from guidelines, facilitates compliance to pharmacologic and non-pharmacologic disease-management interventions, and improves self-management competencies necessary for controlling and managing diseases (Boulet et al., 2019, p. 79). Equally, educating patients and families improve their health literacy and increases their awareness of health conditions, eliminating negative perceptions and beliefs constraining adherence to treatment interventions.

Similarly, effective communication and improving patients’ autonomy promote their ability to collaborate with care coordination teams. Hannigan et al. (2018) contend that care coordination entails engaging, attending, and supporting recovery. Also, coordinated care emphasizes connecting and mobilizing insights from interdisciplinary teams. As a result, improved communication patterns between healthcare professionals and patients can catalyze the transfer of knowledge, wisdom, and information relevant to the overarching objective of facilitating recovery. The endeavor to foster communication between care coordination teams is futile when patients have negligible influence over care processes and decisions. According to Varkey (2021), ensuring patients’ autonomy is one of nurses’ ethical and professional obligations. In this sense, autonomous care recipients know clinical practices and can make informed decisions that improve outcomes. Therefore, safeguarding patient autonomy and effective communication are profound approaches to enhancing collaboration and care coordination.

Change Management Elements of Patients’ Experience

Healthcare professionals are responsible for improving patient experiences and modifying environmental aspects to improve care outcomes. However, they face multiple challenges due to demographic, policy, technological, and socio-cultural changes. As a result, opting for coordinated care is a profound strategy for enabling care providers to navigate these constraints. In the context of team-based interventions for promoting care coordination, an effective change management model is essential in allowing team members to initiate, implement, evaluate, and sustain elements of coordinated care. Further, incorporating change management theories and models into interventions for coordinating care enables healthcare professionals to provide evidence-based care.

Kotter’s eight-step change management theory can facilitate change initiation, implementation, evaluation, and sustenance. According to Carman et al. (2019), this theory has three primary tenets that anchor the eight steps of leading change. These principles include creating a climate of change through building coalitions and partnerships with team members and developing a vision for the team, engaging and enabling the whole organization through empowerment and effective communication, and implementing and sustaining change by anchoring new approaches in the culture. Kotter’s theory of leading change facilitates the assimilation of quality improvement initiatives into organizational culture.

The Rationale for Coordinated Care Plans Based on Ethical Decision-making

Coordinated care plans should consistently anchor ethical decision-making and nurses’ moral and professional obligations to benefit patients, avert harm, safeguard patient autonomy, and ensure justice and fairness when delivering care. According to Haddad & Geiger (2021), the American Nurses Association (ANA) code of ethics for nurses requires them to show compassion and respect for the inherent dignity and unique attributes of every person, demonstrate commitment to the patient, promote and advocate for patient’s rights, promote individual and collective efforts to establish, maintain, and improve the ethical environment of workplace setting, and advance their profession through research and scholarly inquiry. Upholding these ethical considerations when coordinating care plans results in multiple benefits, including complying with the four bioethical principles (beneficence, non-maleficence, autonomy, and justice), improving team-based decision-making processes, promoting evidence-based practice (EPB), and the culture of scholarly inquiry, and cultivating a conducive environment for quality care delivery.

The Potential Impacts of Healthcare Policy Provisions on Outcomes and Patient Experiences

The Affordable Care Act (ACA) of 2010 is a landmark healthcare policy whose provisions significantly impact care coordination, patient outcomes, and experiences. Cleveland et al. (2018) argue that ACA promotes care quality by reducing healthcare expenses, increasing access to convenient care for all Americans, strengthening transformational leadership in care settings, and encouraging innovation and creativity. Equally, this policy established the Hospital Readmissions Reduction Program (HRRP) in 2010, bringing about a value-based purchasing mechanism that enables hospitals to improve communication and care coordination. According to the Centers for Medicare and Medicaid Services [CMS] (2020), the HRRP requires hospitals to engage patients and caregivers in discharge plans to reduce avoidable readmissions. Further, the program rewards or punishes hospitals based on the prevalence of 30-day unplanned readmissions. Although HRRP covers only six conditions, it encourages hospitals to improve transitions, enhance communication between healthcare professionals and patients, and implement follow-up activities to reduce avoidable readmissions.

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The Nurse’s Role in the Coordination and Care Continuum

As I wind up, it is vital to highlight the role of nurses in coordinating care and ensuring a continuum. You should note that nurses understand the intricacies and demands for quality care perpetrated by increased patient populations, technological changes, ever-changing regulations, and the need to uphold bioethical principles. As a result, coordinating care and facilitating a continuum are profound roles of registered nurses. According to Karam et al. (2021), nurses can coordinate care and ensure care continuity through care management, collaborating with patients and families, assessing patients’ needs and goals, linking patients with community resources, facilitating care transitions, developing monitoring and follow-up plans, and encouraging adherence to treatment interventions. Also, they organize case review sessions, provide self-management support, offer technical support, and educate patients and family members. Registered nurses should acknowledge change models and healthcare policies that influence care coordination.  

References

Agency for Healthcare Research and Quality. (2018). Care coordination. https://www.ahrq.gov/ncepcr/care/coordination.html#

Boulet, J., Giannetti, N., Cecere, R. (2019). Patient-centered approach to heart failure management: Transforming care delivery. In: Mesana, T. (eds) Heart teams for treatment of cardiovascular disease. Springer

Carman, A. L., Vanderpool, R. C., Stradtman, L. R., & Edmiston, E. A. (2019). A change-management approach to closing care gaps in a federally qualified health center: A rural Kentucky case study. Preventing Chronic Disease, 16(E105). https://doi.org/10.5888/pcd16.180589

Centers for Medicare and Medicaid Services. (2020). Hospital readmissions reduction program (HRRP). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program

Cleveland, K., Motter, T., & Smith, Y. (2019). Affordable care: Harnessing the power of nurses. Online Journal of Issues in Nursing, 24(2). https://doi.org/10.3912/OJIN.Vol24No02Man02

Haddad, L. M., & Geiger, R. A. (2021). Nursing ethical considerations. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526054

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), 1–14. https://doi.org/10.5334/ijic.3978

Karam, M., Chouinard, M.-C., Poitras, M.-E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, C. (2021). Nursing care coordination for patients with complex needs in primary healthcare: A scoping review. International Journal of Integrated Care, 21(1). https://doi.org/10.5334/ijic.5518

Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119

 

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A. Identify a nursing theory that has influenced your values and goals.

1. Explain how nurses apply the identified theory from part A to implement excellent nursing practices.

2. Discuss how the identified theory from part A fits your professional practice.

 

B. Identify the contributions of two historical nursing figures in the nineteenth or twentieth century.

1. Compare the differences in contributions of the two historical figures identified in part B.

2. Describe how the contributions of the two historical figures influence your professional nursing practice.

 

C. Explain the functional differences between the State Board of Nursing and the American Nurses Association (ANA).

1. Define the roles of these two organizations.

2. Explain how these two organizations influence your nursing practice.

3. Explain the requirements for professional license renewal in your state.

a. Discuss the consequences of failure to maintain license requirements in your state.

4. Compare the differences between registered nursing license requirements in a compact state versus a non-compact state.

 

D. Discuss the functional differences between the Food and Drug Administration and the Center for Medicare and Medicaid Services (see the web links below).

1. Discuss how the two regulatory agencies influence your professional nursing practice.

a. Describe your role as a patient advocate in promoting safety when a patient has requested to use an alternative therapy.

 

E. Discuss the purposes of the Nurse Practice Act in your state and its impact on your professional practice.

1. Discuss the scope of practice for a RN in your state.

2. Discuss how your state defines delegation for the RN.

 

F. Apply each of the following roles to your professional practice:

• a scientist

• a detective

• a manager of the healing environment

 

G. Identify two provisions from the American Nurses Association (ANA) Code of Ethics (see web link below).

1. Analyze how the two provisions identified in part G influence your professional nursing practice.

2. Describe a nursing error that may occur in a clinical practice (e.g., clinical setting, skills lab, or simulation).

a. Explain how the ANA provisions identified in part G can be applied to the error discussed in part G2.

 

H. Identify four leadership qualities or traits that represent excellence in nursing.

1. Discuss the significance of the four leadership qualities identified in part H in the nurse’s role as each of the following:

• a leader at the bedside

• within a nursing team or interdisciplinary team

2. Identify how your work environment impacts the following:

• nursing leadership

• decision making

• professional development

 

I. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.

 

J. Demonstrate professional communication in the content and presentation of your submission.

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RUBRIC
A: NURSING THEORY
NOT EVIDENT

A nursing theory that has influenced the candidate’s values and goals is not identified.

APPROACHING COMPETENCE

The nursing theory is identified, but it is not relevant to the candidate’s values and goals.

COMPETENT

A nursing theory that has influenced the candidate’s values and goals is identified.

A1: EXCELLENT NURSING PRACTICES
NOT EVIDENT

An explanation of how nurses apply the selected theory in part A to plan excellent nursing practices is not provided.

APPROACHING COMPETENCE

The explanation of how nurses apply the selected theory in part A to plan excellent nursing practices is illogical.

COMPETENT

The explanation of how nurses apply the selected theory in part A to plan excellent nursing practices is logical.

A2: PROFESSIONAL PRACTICE NURSING THEORY
NOT EVIDENT

A discussion of how the theory from part A fits the candidate’s professional practice is not provided.

APPROACHING COMPETENCE

The discussion of how the theory from part A fits the candidate’s professional practice is irrelevant, or it inaccurately addresses the identified theory.

COMPETENT

The discussion of how the theory from part A fits the candidate’s professional practice is relevant, and it accurately addresses the identified theory.

B: CONTRIBUTIONS OF 19TH OR 20TH CENTURY HISTORICAL NURSING FIGURES
NOT EVIDENT

An identification of the contributions of 2 historical nursing figures in the nineteenth or twentieth century is not provided.

APPROACHING COMPETENCE

Not applicable.

COMPETENT

The contributions of 2 historical nursing figures in the nineteenth or twentieth century is identified.

B1: DIFFERENCES IN CONTRIBUTIONS
NOT EVIDENT

A comparison of the differences in contributions of the two historical figures discussed in part B is not provided.

APPROACHING COMPETENCE

The comparison inaccurately addresses the differences in the contributions of the 2 historical figures identified in part B, or the comparison is illogical or not supported.

COMPETENT

The comparison accurately addresses the differences in the contributions of the 2 historical figures identified in part B and is logical and well supported.

B2: DESCRIPTION OF HISTORICAL FIGURES
NOT EVIDENT

A description of how the contributions of 2 historical nursing figures have influenced the candidate’s nursing practice is not provided.

APPROACHING COMPETENCE

The description of how the contributions of 2 historical nursing figures have influenced the candidate’s nursing practice is inaccurate.

COMPETENT

The description of how the contributions of the 2 historical nursing figures have influenced the candidate’s nursing practice is accurate.

C: STATE BOARD OF NURSING VERSUS ANA
NOT EVIDENT

An explanation of the functional differences between the State Board of Nursing and the American Nurses Association (ANA) is not provided.

APPROACHING COMPETENCE

The explanation of the functional differences between the State Board of Nursing and the ANA is inaccurate or not supported.

COMPETENT

The explanation of the functional differences between the State Board of Nursing and the ANA is accurate and well supported.

C1: ROLES OF ORGANIZATIONS
NOT EVIDENT

A definition of the roles of the State Board of Nursing and the ANA is not provided.

APPROACHING COMPETENCE

The definition of the role of the State Board of Nursing and the role of the ANA is provided, but it contains inaccuracies, or it is not supported by verifiable facts.

COMPETENT

The definition of the roles of the State Board of Nursing and the ANA is provided and supported.

C2: INFLUENCE OF THE STATE BOARD OF NURSING AND ANA
NOT EVIDENT

An explanation of how the State Board of Nursing and the ANA influence the candidate’s nursing practice is not provided.

APPROACHING COMPETENCE

The explanation of how the State Board of Nursing and the ANA influence the candidate’s nursing practice is inaccurate or irrelevant.

COMPETENT

The explanation of how the State Board of Nursing and the ANA influence the candidate’s nursing practice is accurate and relevant.

C3: REQUIREMENTS FOR PROFESSIONAL LICENSE RENEWAL
NOT EVIDENT

An explanation of the requirements for professional license renewal in the candidate’s state is not provided.

APPROACHING COMPETENCE

The explanation of the requirements for professional license renewal in the candidate’s state is inaccurate or not supported.

COMPETENT

The explanation of the requirements for professional license renewal in the candidate’s state is accurate and well supported.

C3A: FAILURE TO MAINTAIN LICENSE REQUIREMENTS
NOT EVIDENT

A discussion of the consequences of failure to maintain license requirements in the candidate’s state is not provided.

APPROACHING COMPETENCE

The discussion of the consequences of failure to maintain license requirements in the candidate’s state is inaccurate.

COMPETENT

The discussion of the consequences of failure to maintain license in the candidate’s state is accurate.

C4: COMPACT VERSUS NON-COMPACT STATE
NOT EVIDENT

A comparison of the differences between registered nursing license requirements in a compact state versus a non-compact state is not provided.

APPROACHING COMPETENCE

The comparison inaccurately addresses the differences between registered nursing license requirements in a compact state versus a non-compact state, or it is not supported.

COMPETENT

The comparison accurately addresses the differences between registered nursing license requirements in a compact state versus a non-compact state and is well supported.

D: AGENCIES FUNCTIONAL DIFFERENCES
NOT EVIDENT

A discussion of the functional differences between the given regulatory agencies is not provided.

APPROACHING COMPETENCE

The discussion of the functional differences between the given agencies is inaccurate or not supported.

COMPETENT

The discussion of the functional differences between the given agencies is accurate and well supported.

D1: INFLUENCE ON PROFESSIONAL PRACTICE
NOT EVIDENT

A discussion of how the regulatory agencies influence the candidate’s professional nursing practice is not provided.

APPROACHING COMPETENCE

The discussion of how the regulatory agencies influence the candidate’s professional nursing practice is irrelevant.

COMPETENT

The discussion of how the regulatory agencies influence the candidate’s professional nursing practice is relevant.

D1A: NURSE’S ROLE AS A PATIENT ADVOCATE
NOT EVIDENT

A discussion of the candidate’s role as a patient advocate in promoting safety when the patient has selected an alternative treatment is not provided.

APPROACHING COMPETENCE

The discussion of the candidate’s role as a patient advocate in promoting safety when the patient has selected an alternative treatment is not relevant.

COMPETENT

The discussion of the candidate’s role as a patient advocate in promoting safety when the patient has selected an alternative treatment is relevant.

E: PURPOSES OF THE NURSE PRACTICE ACT
NOT EVIDENT

A discussion of the purposes of the Nurse Practice Act and its influence on the candidate’s professional practice is not provided.

APPROACHING COMPETENCE

The discussion of the purposes of the Nurse Practice Act and its influence on the candidate’s professional practice is inaccurate, or it is not supported.

COMPETENT

The discussion of the purposes of the Nurse Practice Act and its influence on the candidate’s professional practice is accurate and well supported.

E1: SCOPE OF PRACTICE
NOT EVIDENT

A discussion of the scope of practice for an RN in the candidate’s state is not provided.

APPROACHING COMPETENCE

The discussion of the scope of practice for an RN in the candidate’s state is illogical or unsupported.

COMPETENT

The discussion of the scope of practice for an RN in the candidate’s state is logical and well supported.

E2: RULES FOR EFFECTIVE DELEGATION
NOT EVIDENT

A discussion of how the candidate’s state defines delegation for the RN is not provided.

APPROACHING COMPETENCE

A discussion of how the candidate’s state defines delegation for the RN is illogical or not supported.

COMPETENT

The discussion of how the candidate’s state defines delegation for the RN is logical and well supported.

F: APPLICATION OF NURSING ROLES
NOT EVIDENT

A discussion of the application of each nursing role to the candidate’s professional practice is not provided.

APPROACHING COMPETENCE

The discussion of the application of each nursing role to the candidate’s professional practice is irrelevant.

COMPETENT

The discussion of the application of each nursing role to the candidate’s professional practice is relevant.

G: ANA CODE OF ETHICS PROVISIONS
NOT EVIDENT

2 provisions from the ANA Code of Ethics are not identified.

APPROACHING COMPETENCE

2 provisions from the ANA Code of Ethics are identified, but they are inaccurate.

COMPETENT

2 provisions from the American Nurses Association (ANA) Code of Ethics are accurately identified.

G1: ANALYSIS OF PROVISIONS
NOT EVIDENT

An analysis of how the 2 provisions identified in part G influence the candidate’s professional nursing practice is not provided.

APPROACHING COMPETENCE

The analysis inaccurately addresses how the 2 provisions identified in part G influence the candidate’s professional nursing practice, or the analysis is not reasoned.

COMPETENT

The analysis accurately addresses how the 2 provisions identified in part G influence the candidate’s professional nursing practice and the analysis is reasoned.

G2: CLINICAL PRACTICE ERROR
NOT EVIDENT

A description of a nursing error in a clinical practice example is not provided.

APPROACHING COMPETENCE

The description of a nursing error in a clinical practice example is irrelevant.

COMPETENT

The description of a nursing error in a clinical practice example is relevant.

G2A: APPLICATION OF ANA PROVISIONS
NOT EVIDENT

An explanation of how ANA provisions in part G can be applied to the error from part G2 is not provided.

APPROACHING COMPETENCE

The explanation of how the ANA provisions in part G can be applied to the error from part G2 is irrelevant.

COMPETENT

The explanation of how the ANA provisions in part G can be applied to the error from part G2 is relevant.

H: LEADERSHIP QUALITIES OR TRAITS
NOT EVIDENT

4 leadership qualities or traits are not identified.

APPROACHING COMPETENCE

4 leadership qualities or traits are identified, but they do not represent excellence in nursing, or they are otherwise inappropriate for a nursing practice.

COMPETENT

4 leadership qualities or traits that represent excellence in nursing are identified, and are appropriate for a nursing practice.

H1: DEMONSTRATION OF NURSING LEADERSHIP QUALITIES OR TRAITS
NOT EVIDENT

A discussion of how the nurse uses the identified leadership qualities or traits in part H in each of the given roles is not provided.

APPROACHING COMPETENCE

The discussion of how the nurse uses the identified leadership qualities or traits in part H does not include each of the 4 traits, does not include each of the given roles, or it is not relevant.

COMPETENT

The discussion of how the nurse uses the identified leadership qualities or traits in part H includes each of the 4 traits, includes each of the given roles, and it is relevant.

H2: WORK ENVIRONMENT
NOT EVIDENT

An identification of how the work environment impacts each given point is not provided.

APPROACHING COMPETENCE

The submission identifies how the work environment is impacted, but it does not provide relevant details or examples of how each given point is impacted.

COMPETENT

The submission identifies of how the work environment is impacted, and provides relevant details and examples of how each given point is impacted.

I: APA SOURCES
NOT EVIDENT

The submission does not include in-text citations and references according to APA style for content that is quoted, paraphrased, or summarized.

APPROACHING COMPETENCE

The submission includes in-text citations and references for content that is quoted, paraphrased, or summarized but does not demonstrate a consistent application of APA style.

COMPETENT

The submission includes in-text citations and references for content that is quoted, paraphrased, or summarized and demonstrates a consistent application of APA style.

J: PROFESSIONAL COMMUNICATION
NOT EVIDENT

Content is unstructured, is disjointed, or contains pervasive errors in mechanics, usage, or grammar. Vocabulary or tone is unprofessional or distracts from the topic.

APPROACHING COMPETENCE

Content is poorly organized, is difficult to follow, or contains errors in mechanics, usage, or grammar that cause confusion. Terminology is misused or ineffective.

COMPETENT

Content reflects attention to detail, is organized, and focuses on the main ideas as prescribed in the task or chosen by the candidate. Terminology is pertinent, is used correctly, and effectively conveys the intended meaning. Mechanics, usage, and grammar promote accurate interpretation and understanding.

WEB LINKS
Center for Medicare and Medicaid Services
Code of Ethics
Food and Drug Administration