Effective strategies for collaborating with patients and their families to achieve desired health outcomes.
Preparation
You are encouraged to complete the Managing Change activity. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment.
Scenario
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.
Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact [email protected] to request accommodations.
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.
Note: You are not required to deliver your presentation.
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 video. Include your source citations on a references page appended to your narrative script. Explore the resources about effective presentations as you prepare your assessment.
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.
Video Presentation Script on Care Coordination Basics for Nursing Colleagues
Introduction
Good morning, everyone. Today, I'm excited to discuss the fundamental principles of care coordination, covering community resources, ethical issues, and policy issues that affect the coordination of care.
What is Care Coordination?
Care coordination is a crucial aspect of healthcare delivery, ensuring that patients receive comprehensive, integrated care across various settings and providers. It involves deliberately organizing patient care activities and sharing information among all healthcare stakeholders to achieve safer, more effective, and patient-centered care.
Why is Care Coordination Important?
Effective care coordination offers numerous benefits, including:
- Improved Patient Outcomes: Coordinated care leads to better adherence to treatment plans, reduced healthcare utilization, and improved overall health outcomes.
- Enhanced Patient Experience: Patients feel more empowered and satisfied when their care is coordinated, as they receive clearer communication, reduced duplication of services, and a more seamless healthcare experience.
- Reduced Healthcare Costs: Coordinated care helps avoid unnecessary tests, procedures, and hospitalizations, leading to lower healthcare costs.
Key Factors for Effective Care Coordination
Involving nurses in care coordination is essential for achieving these benefits. Nurses play a pivotal role in:
- Patient Assessment and Goal Setting: Nurses assess patients' needs, preferences, and goals, collaborating with them to develop individualized care plans.
- Care Plan Implementation and Monitoring: Nurses implement care plans, monitor patient progress, and coordinate interventions with other healthcare team members.
- Patient Education and Self-Management Support: Nurses provide patient education, promote self-management, and empower patients to make informed decisions about their health.
- Care Transitions Management: Nurses facilitate smooth transitions between care settings, ensuring continuity of care and preventing gaps in service.
- Community Resource Linkage: Nurses connect patients with appropriate community resources, such as social services, support groups, and transportation assistance.
Community Resources
Effective care coordinators should be familiar with available community resources to address patients' social determinants of health, such as:
- Social Services: These services provide assistance with housing, food, financial aid, and other basic needs.
- Support Groups: These groups provide emotional support, education, and peer-to-peer connections for patients facing specific health challenges.
- Transportation Assistance: These services provide transportation to medical appointments, grocery stores, and other essential destinations.
- Mental Health Services: These services provide counseling, therapy, and medication management for individuals struggling with mental health conditions.
- Substance Abuse Treatment: These services provide counseling, detoxification, and rehabilitation programs for individuals with substance abuse issues.
Ethical Issues in Care Coordination
Nurses must consider ethical principles when coordinating care, such as:
- Patient Autonomy: Respecting patients' right to make informed decisions about their care.
- Informed Consent: Obtaining clear and informed consent for procedures and treatments.
- Confidentiality: Protecting patients' privacy and safeguarding their personal health information.
- Social Justice: Promoting equitable access to quality care and addressing healthcare disparities.
- End-of-Life Care: Ensuring respectful and compassionate care for patients facing end-of-life decisions.
Policy Issues in Care Coordination
Healthcare policies significantly impact care coordination, such as:
- Affordable Care Act (ACA): The ACA expanded access to health insurance and promoted patient-centered care, leading to improved care coordination efforts.
- Health Information Technology (HIT): Electronic health records (EHRs) and other HIT tools facilitate information sharing and enhance care coordination across providers.
- Value-Based Payment Models: These models incentivize coordinated care, rewarding providers for achieving better patient outcomes and lower costs.
- Accountable Care Organizations (ACOs): ACOs promote coordinated care by bringing together providers to manage population health and share financial risk.
- Patient-Centered Medical Homes (PCMHs): PCMHs emphasize coordinated care through a centralized care team approach.
Collaborating with Patients and Families
Effective care coordination hinges on strong collaboration with patients and their families. Strategies include:
- Patient-Centered Communication: Actively listen to patients' concerns, provide clear explanations, and encourage open communication.
- Cultural Competence: Understand and respect patients' cultural values, beliefs, and healthcare practices.
- Family Involvement: Encourage family involvement in care decisions, considering their roles as caregivers and advocates.
- Shared Decision-Making: Involve patients and families in making informed decisions about their care, aligning treatment plans with their preferences and goals.
- Drug-Specific Education: Provide clear and tailored education about medications, including dosage, side effects, and potential interactions.
Change Management in Care Coordination
Implementing care coordination often involves organizational change, which requires careful planning and