NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project

NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project

Planning and Presenting a Care Coordination Project

Hello to Everyone. My name is Valtrice, and the topic of our conversation today is how to organize and deliver a plan for chronic care patients’ care coordination to decision-makers. 

A chronic ailment is one that lasts for a year or longer, necessitates continuing medical care, and prevents a person from doing daily chores. The principal causes of death and impairment in the US are chronic illnesses like hyperglycemia, malignancies, and cardiovascular diseases. Additionally, they contribute to the state’s $4.5 trillion yearly health maintenance expenditures (Nugent, 2019). Several chronic beneficial conditions include anxiety, hypertension, hyperglycemia, TB, prolonged bronchitis, heart disease, alcoholic liver disease, and hyperglycemia. If chronic illnesses are not treated effectively, they may result in impairment.

Care coordination requires organizing healthcare demands and communicating them to every one of the care team in order to ensure that they are met during the duration. As part of treatment, chronic illness symptoms must be managed. A comprehensive health approach is required for managing chronic illnesses. Nurses may assist patients with managing their symptoms, limiting the course of their illness, and getting their life back to normal with the aid of a well-established disease management program (Tharani et al., 2021).

The Vision of Coordinated Care for Chronic Care Patients

For individuals undergoing routine illness medication, individuals who have already been diagnosed with a life-threatening illness, and their family members, as well as for clinical staff seeking to consistently deliver disease care, care coordination is a crucial concern. Coordination is the process of bringing together the objectives and choices made by the many major stakeholders in the patient’s care. It also explains how several care coordinators and other medical professionals coordinate, schedule, and modify crucial care tasks.  Research is still being done to improve follow-up plans for unfavorable testing findings, primarily irregular ovarian preventive medicine and fecal occult blood test results. A lot of “hidden labor” is performed by patients and nurses to organize care, according to studies on maintenance distribution patterns and patient perceptions. An organization without a medical record system may incur significant additional time and costs due to absence, poor decision-making, poor communication, and rising costs (Allegrante et al., 2019).

NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project

Concepts For Organizing and Strengthening Care

The significant concerns that healthcare organizations address on chronic care patients are listed below:

  • Understand the significance of care coordination for people with chronic diseases and the practices that support their management and prevention plans.
  • Establishing precise and pertinent metrics that can be used to assess the success of treatments intended to address care coordination issues and understand the underlying causes of these issues. 
  • Patients, caregivers, and managers of illness care organizations can achieve disease management milestones with the help of modifying and evaluating medicines.

In this discussion, we discuss opportunities to investigate these issues from three points of view along the chronic care patient’s maintenance spectrum: 

  1. Communication, with a focus on planning follow-up for conflicting findings. 
  2. Robust treatment, with a focus on issues corresponding to facilitating coordinated care within and between oncology and appropriate care.
  3. Overall survival (Garland, & Fraser, 2018).

Organizations and Groups for Chronic Care Patients

Healthcare facilities, pharmacies, and other medical centers frequently see patients with chronic conditions. They frequently require cash support for things like medical fees and health insurance. Numerous groups support people who become separated and estranged because of their condition. The following groups have received recognition for their outstanding work in helping those who have health issues.

SHARE: A group that offers supportive services and vital information to people with breast cancer. It is a non-profit organization. They also run counseling services, educational projects, and public health campaigns, and provide a multilingual toll-free helpdesk. Although women from throughout the globe are welcome to call the institution’s hotline and use their teaching materials, the organization’s main office is in the New York City area (Rabbani, 2021).

Patient Airlift Services: Patients who require quick medical assistance can book flights through Patient Airlift Services (PALS), a charitable aircraft company. Since the program’s inception in 2010, they have collected more than 24,000 flights, assisting families and US military personnel nationwide (VanDijck et al., 2021).

Gracie’s Gowns handcrafts: For little or no expense, Gracie’s Gowns handcrafts distinctive regular clothes for kids with fatal illnesses. They ship their outfits to all US states as well as other nations across the world. They wish to provide children with something special and pleasurable to wear during tough situations (Rabbani, 2021).

Good Days: It assists those without insurance who have chronic illnesses in paying for their necessary pharmaceuticals. This group offers monetary support by paying for medical care and prescription medication. They occasionally aid those in need with the cost of their health insurance. 

NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project

Examination of Environmental and Provider Resources

Even when making changes will improve patient care and supplier competency, implementing them into a healthcare institution’s strategic plan and day-to-day procedures can be challenging. Fortunately, there are tools available for anyone who wants to understand how to handle primary monitoring with a well-thought-out plan (Markle et al., 2018). Utilizing previous research, the Care Coordination Quality Measure for Primary Care (CCQM-PC) creates a conceptual base for care management. By assessing individuals’ abilities with care coordination in primary care environments, the CCQM-PC seeks to close a gap in the analysis of care organizations. To accurately measure patients’ perceptions of the quality of their interactions with care management, a questionnaire was developed, conceptually validated, and administered to patients from different groups of 15 primary care clinics. The full analysis is also provided, and since it is in the public domain, anyone may modify it and use it without additional permission (Nekhlyudov et al., 2019).

Financial Resources Required by Chronic Care Patients

Due to the difficulty of managing a chronic illness, people may have to miss important get-togethers with relatives and friends. The burden of high medical costs is increased, which could cause patients to put off receiving critical care. There are several ways to get the assistance required, regardless of whether they or a beloved has a Disease, neurodegenerative disorder, or some other chronic illness (Gupta et al., 2020).

Many institutions help, including monetary support for immunological and genetic conditions that are persistent. However, some programs focus on specific disorders; others offer financial assistance for reasonable medical costs. Every program has a specific software procedure and requirements for eligibility. Various administration programs may be available to those with chronic illnesses, but the qualifications are stringent. A collection of resources and initiatives that people might find useful is provided below:

  • Medicare is a federal health insurance program for seniors and others. Hospitalization services, physician services, certain residential care, pharmaceutical drugs, health products, and hospice are just a few of the numerous fundamental health services that are covered. 
  • To support projects for chronic illness self-management, Work Health and Safety Policy plays a vital role

Project Milestones and Outcomes

Creating an organization’s goals and objectives is the initial stage. The operational data and materials required for a chronic care management program should be included in this strategy. To address this added responsibility, the personnel need to be trained, necessitating the appointment of care managers. A care manager for a chronic care program must either be a physician or one of the skilled personnel i.e., a licensed practical nurse; or a registered nurse, licensed medical assistant; or health care provider as per CMS criteria (Garland, & Fraser, 2018).

Finding patients who are qualified for chronic care management is the following stage (CCM). It is anticipated that the condition will persist for at least one year or until the individual passes away. The likelihood that the patient may pass away, experience an acute recurrence, decompose, or lose function is considerably increased by the illness. The qualified patients who were chosen and granted consent to participate in the program must now be enrolled. A patient must first schedule an in-office consultation with the medical professional if they have consented to participate in CCM but haven’t seen a doctor in the previous one and a half years. Giving patients Annual Wellness Visits (AWVs) to acquaint them with the CCM program is a brilliant option. (Yeoh et al., 2018).

The time has come to plan the patient’s care. The first and most crucial step ought to be to create a patient-centered care plan. Afterward, they are finished, give the patient a copy of the treatment plan and distribute it to any additional medical personnel who might require seeing it. A patient portal could be very useful for keeping people interested in their health. The patient portal streamlines focused monthly care interactions, enhances coordination and communication between patients and doctors, and provides patients with access to therapeutic interventions (Yeoh et al., 2018).

Anticipated Outcomes

The tough situations must be faced by individuals who are experiencing long-term chronic diseases. They have access to multiple health networks where they can see a variety of medical experts. Maintaining control over this could not be simple. Using chronic care management, patients can control the numerous working parts of their therapies. Their care team might collaborate rather than consist of numerous providers who are not communicating well with one another. A coordinated care team collaborates to ensure that every component of the patient’s treatment is orchestrated as one moving part. Coordinating care makes sure patients receive the additional assistance they require (Knopp et al., 2022). There are occasional gaps in the care of persons with various chronic diseases. Numerous factors, including poor communication, confusion, or service provider failure, may be to blame for this. In each situation, Chronic Care Management seeks to avoid care gaps. 

To ensure that the patient is on course to attain optimal health results, this program makes sure that somebody checks in with them at least once every month (Knopp et al., 2022). If someone is responsible for holding patients responsible for following their treatment plan, they are more likely to achieve greater health results. Patients can contact these experts whenever they have questions. Additionally, care coordination enables people to keep track of their medications and notify specialists of any irregularities or red flags in their treatment. Due to the interdependence of all these moving parts, patients who implement chronic care management experience better outcomes. (Sur et al., 2022). Chronic care management may result in considerable compensation increases for providers. The annual increment per healthcare policy for a clinic might reach $90,000. Working with a reputed CCM partner may speed up the Chronic Care Management program and increase revenue.

Presentation of Project to Decision Makers

There will be a need for both modest and massive spending to alter the healthcare delivery system. Communication and care coordination will be essential. The personnel must be planned for as a top concern. Through interaction and coordination, overlapping operations may help avoid wasting resources and time or promote patient ” silent treatment.”

When weighing the expense and the efficiency of the present systems, it is essential to comprehend the relative efficacy of the patient’s therapy. Spending money on quality assessments would give precise information that could motivate improving healthcare delivery by showing how much the patient’s health has improved. Platforms that facilitate access to and sharing of patient data with relevant people are being developed by healthcare technology businesses like Rainbow Health. A digital site where instructions can be exchanged with others concerned about the patient’s health and well-being is essential. During routine visits, a brief check-in, test findings, or even something as straightforward as making sure the patient has access to nutrition and travel (Anderson, & Hewner, 2021). One of the key challenges to modernizing patient care delivery is health financing systems. Too frequently, suppliers reap unintended rewards by providing redundant services, useless services, and activities that raise costs. Utilizing outcome-based data and improving provider communication could mitigate these problems.

NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project


The future of the American healthcare system will involve the synchronization of preventative healthcare for the treatment of chronic ailments. For those with limited resources, this disease management strategy which encourages people to keep track of their health through regular interaction with teams providing healthcare, might be helpful. Since poor people commonly try to overcome the progression of chronic diseases like hyperglycemia and pneumonia, they may benefit from this sort of care delivery. This could even be more significant. Psychologists must also be used to improve patient knowledge of and compliance with drug regimes. From a social and economic standpoint, changing health management procedures to reduce disparities between wealthy and underprivileged patients is probably favorable for the US healthcare system.


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