Care Coordination Presentation to Colleagues

Introduction

NURS FPX 4050 Assessment 3 Care Coordination Presentation to Colleagues NR

Good morning fellow nurses, and welcome to this presentation today. I am honored to be standing before you this wonderful day to discuss a crucial topic we are all familiar with on some level, care coordination. It is common for patients to have a team of physicians or caregivers who play a vital role in their overall health outcomes. By creating a coordinated care model of healthcare providence, instead of alienation, each team member will be better suited to care for the patient through direct or indirect communication, having access to each other’s latest notes on patient health records (Williams, 2019). I will take this time today to discuss some strategies to effectively collaborate with patients and their families to achieve the best outcomes and outline some ethical considerations regarding care coordination. We will also be looking at some change management strategies and how the affordable care act (ACA) plays a role in care coordination.

Care Coordination

Care coordination seeks to effectively reduce the fragmentation and communication breakdowns within healthcare systems by providing all care team members with relevant, up-to-date information regarding a patient’s health (Williams, 2019). The idea is that through careful collaboration, hospitalizations, rehospitalizations, and healthcare costs can be significantly reduced while at the same time promoting better health and wellness outcomes for patients. As registered nurses (RN), we play a crucial part in ensuring that care coordination is successful and the continuum of care remains unbroken. RNs are often the chain that links multiple specialists together, and we are also typically the entity that patients and their families trust the most (McCarthy, 2021). As such, we play an essential role in care coordination by providing all stakeholders with relevant updates in a timely manner.

Coordinated Care Based on Ethical Decision Making

This is a good time to segue way into the next important topic for today’s presentation, which is providing coordinated care that is firmly based on ethical decision-making. As I previously hinted, nursing is the most trusted profession (McCarthy, 2021), giving us a unique position of power. Patients at their lowest points tend to share and frequently overshare information with RNs leaving us responsible for deciding what we do with that sensitive information. This is where the nursing code of ethics becomes extremely important, as all decisions should be based on its tenets of beneficence, nonmaleficence, justice, and autonomy (Varkey, 2021). 

           The three most important ethical principles are beneficence, justice, and autonomy in this instance. In the case of coordinated care, information sharing becomes vital to helping the progression of care. While a nurse may think that certain privately shared information could benefit the patient’s care, the ethical principle of autonomy requires the nurse to allow the patient the right to communicate or withhold that information (Varkey, 2021). Considering the principle of justice and fairness, the RN may give the patient their educated reasoning for why it may be in the patient’s best interest to disclose certain information. Still, it is ultimately the patient’s decision.

Furthermore, the ethical principle of beneficence requires that the RN always does the right thing for the patient. As such, the RN must respect the patient’s trust by keeping patient information confidential. Respecting a patient’s privacy is part of the ethical principle of beneficence and plays into the responsibility that comes with the RNs role of advocating for the patient. Beyond the RN, these principles also apply to the entire care team since they are handling the patient’s protected health information (PHI) as defined under The Health Insurance Portability and Accountability Act (HIPAA) (Edemekong, 2022).

The Affordable Care Act and Care Coordination

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On a national level, no legislation has played a more significant role in enhancing the efforts of care coordination than the Affordable Care Act (ACA) signed into law by President Obama in 2010. The ACA focused on three main goals: to provide affordable insurance to all Americans, expand Medicaid coverage for those living under the poverty line, and reduce overall healthcare costs and expenditure. These goals created newfound opportunities for improved care coordination by creating Affordable Care Organizations (ACOs). ACOs allow patients to receive care from one holistic organization, with multiple experts providing coordinated care at cheaper or bundled rates (Moy, 2022). Furthermore, the ACA also sets specific quality benchmarks that ACOs must meet to continue receiving Medicaid and Medicare benefits.

Strategies for Collaboration with Patients and their Families

For any successful collaborative effort to work, there needs to be buy-in from all parties involved. This is no different when garnering the collaboration and support of patients and their families concerning care coordination. The first step in ensuring we have patient and family buy-in is to ensure that the patient feels they have a voice in their care. The second is to make sure we as the RNs understand the family dynamics and role that each family member plays as a caretaker or stakeholder in their loved one’s care. We must remember to maintain patient privacy when discussing medical issues with family members and only disclose information the patient is okay with being revealed.

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           It is also critical that the family members understand and recognize our appreciation of their willingness to step in. In most situations, family members are working for free, and it can also take a toll on their health and wellbeing depending on the severity of the patients’ ailment. Recognizing this and providing family members with resources such as respite care and support group information will help build trust and a sense of comradery (Zarit, 2017). This can further enhance the overall care coordination process by spreading the workload and having more eyes on the patient.

Change Management and How it Affects the Patient Experience

People are naturally resistant to change, and without careful management, the process can be unfruitful and fail miserably. Therefore, it is essential to start any change management initiative with proper education and clearly defined goals (Nilsen, 2020). Results show that change management is most successful when the primary stakeholders are involved in the change process and can provide feedback and input towards the process. A system that is fully engaged in the change process and is willing to work together will most likely succeed without any significant setbacks. It is critical that the patient feels that their needs are at the forefront of the change process and that they understand how the new changes will improve their overall health and wellbeing (Nilsen, 2020). The perceived benefits for the patient are also important for the providers, nurses, and staff to recognize to receive the necessary buy-in to ensure success.

NURS FPX 4050 Assessment 3 Care Coordination Presentation to Colleagues NR

Nurses Role in Care Coordination and Continuum

Throughout this presentation, I have made many references to the vital role that the RN plays in ensuring that care coordination is successful. To summarize, based on the nursing practice’s trust, closeness to the patient, and overall philosophy, nurses, play a crucial role in the success or failure of proper care coordination. Together, we hold the keys that open all the doors as we are often the middlemen between multiple providers, healthcare facilities, and even family disagreements. As long we stick to the principles we promised to uphold and place nursing ethics at the forefront of our decisions, the patient will remain protected. Thank you so much for your time, and I hope you learned something here today. Have a fantastic day and week ahead.

References

Williams, M. D., Asiedu, G. B., Finnie, D., Neely, C., Egginton, J., Finney Rutten, L. J., & Jacobson, R. M. (2019, February 1). Sustainable care coordination: A qualitative study of primary care provider, administrator, and insurer perspectives. BMC health services research. Retrieved March 9, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6359857/ 

McCarthy, N. (2021, June 29). America’s most & least trusted professions [infographic]. Forbes. Retrieved March 10, 2022, from https://www.forbes.com/sites/niallmccarthy/2019/01/11/americas-most-least-trusted-professions-infographic/?sh=40f9493a7e94

Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical principles and practice: international journal of the Kuwait University, Health Science Centre. Retrieved March 10, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7923912/ 

Edemekong PF, Annamaraju P, Haydel MJ. Health Insurance Portability and Accountability Act. [Updated 2022 Feb 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK500019/

Moy HP, Giardino AP, Varacallo M. Accountable Care Organization. [Updated 2022 Feb 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448136/

Zarit, S. H., Bangerter, L. R., Liu, Y., & Rovine, M. J. (2017, March). Exploring the benefits of respite services to family caregivers: Methodological issues and current findings. Aging & mental health. Retrieved March 10, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5550302/ 

Nilsen, P., Seing, I., Ericsson, C., Birken, S. A., & 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), 147. https://doi.org/10.1186/s12913-020-4999-8