Care Coordination Presentation to Colleagues

Hello everyone, welcome to a care coordination presentation. My name is (Insert Name Here). In this presentation, we shall discuss the tenets of care coordination, the rationale of coordinating care based on ethical considerations, the inputs of various public health policies on care coordination, and summarize our discussion by reflecting on the nurse’s role in coordinating care. Before that, I would like you to imagine a scenario where healthcare institutions and caregivers operate without involving patients and other healthcare organizations. Undeniably, such a situation can compromise care quality by limiting the prospect of interdisciplinary collaboration and patient-centered care.

How do we define care coordination?

Undoubtedly, care coordination is a multi-faceted concept that lacks a universal definition due to the interplay between its components. However, the US Agency for Healthcare Research and Quality (AHRQ, 2018) defines care coordination as an approach that entails “deliberately organizing patient care activities and sharing information among all participants concerned with a patient’s care to achieve safer and more effective care.” The AHRQ’s definition of card coordination tries to capture the overriding themes consistent with coordinated care and patient-centered services. These themes include effective communication, timely information-sharing mechanisms, and care organization which encompasses the process of care planning.

The Agency for Healthcare Research and Quality (AHRQ) categorizes care coordination elements into two categories: broad and specific care approaches. The first category accommodates strategies such as teamwork, care management, medication management, incorporation of health information technology, and patient-centered care. On the other hand, the specific care coordination activities include establishing accountability and agreeing on responsibility, communicating knowledge, assessing patient needs and goals, creating a proactive care plan, and linking care recipients to community resources (AHRQ, 2018). Although these components of coordinated care form the basis of individualized quality and convenient care, their effectiveness relies massively upon patient participation and upholding ethical standards for nursing practice.

Effective Strategies for Collaborating with Patients and their Families

Implementing patient-centered care is a profound strategy for facilitating care coordination because it accommodates aspects of value-based coordinated care. According to Santana et al. (2018), patient-centered care (PCC) entails aligning care structures, processes, and outcomes with patients’ needs and goals. Therefore, PCC encompasses effective communication, respectful and compassionate care, patient engagement in consensus decision-making, patient-reported outcomes, and redesigning organizational culture to shift from caregivers-centered to patient-oriented care interventions.

As stated earlier, care coordination entails broad and specific components that revolve around communication patterns between healthcare professionals and patients, need and goal assessments, care management, interdisciplinary team collaboration, and planning for care, including developing strategies for monitoring patient’s progress through follow-up activities. It is essential to note that these components resonate with the foundation principles of patient-centered care. As a result, patient-centered care and care coordination inseparable concepts in the current healthcare systems.

Aspects of Change Management that Affect Patient Experience

The health sector is ever-dynamic considering demographic, policy, technological, and socio-cultural changes. For instance, the increased demand for quality care due to the upsurging population prompts healthcare professionals to incorporate aspects of change management. According to Nilsen et al. (2020), health institutions can cope with the inevitable changes if healthcare professionals can act as change advocates and value the tenets of change, including incorporating new technologies when providing care. The Department of Evidence and Intelligence for Action in Health (EIH, 2019) identifies the six aspects of change management that determine how health organizations thrive in dynamic environments; governance and leadership, stakeholder engagement, communication, training and education, monitoring and evaluation, and workflow analysis and redesign. These components of change management affect patient outcomes and experiences towards health services.

Effective governance and leadership enable healthcare professionals to understand the strategic view and reasoning behind the change process. In this sense, it is possible to align individual skills and knowledge with the change process (EIH, 2019). Secondly, stakeholder engagement underscores the rationale of interdisciplinary collaboration, effective communication, and enhanced stakeholder participation in implementing change. Thirdly, workflow analysis and system redesigning entail transforming organizational structures and systems to accommodate the change process. For example, health institutions should consolidate resources and avail systems that support advanced health technologies such as telehealth, clinical decision support systems (CDSS), and artificial intelligence (AI). Undoubtedly, these change management components bolster patients’ outcomes and experiences by emphasizing care quality and supporting advanced approaches for promoting patient safety.

The Importance of Coordinating Care Based on Ethical Decision-Making

As stated earlier, interdisciplinary collaboration and patient-centered care are essential aspects of coordinated care. The interplay between team performance, patient-centered care, and care coordination renders the ethical decision-making process a prerequisite for effective care coordination. In this sense, healthcare professionals are responsible for incorporating and adhering to ethical standards that influence decisions. Haddad & Geiger (2021) argues that the American Nursing Association (ANA) developed the Code of Ethics that requires nurses to practice with compassion and respect patients’ inherent dignity, worth, and unique attributes. In this sense, care providers should coordinate care based on consensus and ethical decisions that enable patients to control and influence care trajectories.

Consensus and ethical healthcare decisions are consistent with the bioethical principle of patient autonomy. Varkey (2020) argues that “all persons have intrinsic and unconditional worth, and therefore, should have power to make rational decisions and moral choices, and each should be allowed to exercise his or her capacity for self-determination” (p. 19). Reserving patients’ autonomy to decide care trajectories translates to ethical and collective decisions that promote patient satisfaction and enable care providers to address incidences of ethical dilemmas.

Impact of Healthcare Policy on Patient Outcomes and Experiences.

It is essential to note that public health policies in the US focus on improving public health, safeguarding patient safety, and averting threats to well-being. Although many policies contribute to improved health and well-being, the Affordable Care Act (ACA) of 2010 remains a landmark policy in changing the trajectories of coordinated care. For instance, ACA encourages health organizations to coordinate care by implementing the Hospital Readmissions Reduction Program (HRRP) of 2012. According to the Centers for Medicare and Medicaid Services (CMS, 2021), the HRRP is a Medicare value-based purchasing program that encourages hospitals to improve communication and coordinate care to reduce avoidable readmissions. This provision identifies patient engagement in the discharge plan as an ideal strategy for coordinating care and averting the risk of re-hospitalization. Further, the HRRP encourages follow-up activities, effective communication, and pre-discharge education to enhance patient outcomes and experiences before and after discharge. These aspects contribute to care quality and improved patient safety.

The Role of Nurses in Care Coordination and Continuum

As I conclude, it is essential to discuss the nurses’ significant role in coordinating care and ensuring care continuity. Nurses are responsible for implementing the components of care coordination. As stated earlier, some components of coordinated care include effective communication, information sharing mechanisms, patient need and goal assessments, care management, and the development of care plans. Karam et al. (2021) argue that nurses can coordinate care by engaging patients in consensus decision-making processes, encouraging interdisciplinary collaboration, assessing patient needs and goals, and planning/implementing follow-up activities. Finally, nurse practitioners enjoy prospective and meaningful relationships with patients, enhancing their chances of coordinating care. From this contention, I wish to conclude my presentation by believing that it has transformed your perspective of care coordination and your role in coordinating care. Thank you all for listening to this presentation. Kindly feel free to ask questions or add suggestions regarding the topic.

References

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

CMS. (2021, January 12). Hospital readmissions reduction program (HRRP). Retrieved March 23, 2022, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program

Department of Evidence and Intelligence for Action in Health. (2019). Change Management in Public Health (pp. 1-8). Retrieved from https://www3.paho.org/ish/images/toolkit/IS4H-KCCM-EN.pdf

Haddad, L. M., & Geiger, R. A. (2021, August 30). Nursing ethical considerations. StatPearls [Internet]. Retrieved March 22, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK526054/

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), 16. https://doi.org/10.5334/ijic.5518

Nilsen, P., Seing, I., Ericsson, C., Birken, S., & Schildmeijer, K. (2020). Characteristics of successful changes in health care organizations: An interview study with physicians, registered nurses, and assistant nurses. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-020-4999-8

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