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Care Coordination Presentation to Colleagues

Develop a 20-minute presentation for nursing colleagues highlighting the fundamental principles of care coordination. Create a detailed narrative script for your presentation, approximately 4-5 pages in length, and record a video of your presentation.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

Competency 2: Collaborate with patients and family to achieve desired outcomes.

Outline effective strategies for collaborating with patients and their families to achieve desired health outcomes.

Competency 3: Create a satisfying patient experience.

Identify the aspects of change management that directly affect elements of the patient experience essential to the provision of high-quality, patient-centered care.

Competency 4: Defend decisions based on the code of ethics for nursing.

Explain the rationale for coordinated care plans based on ethical decision making.

Competency 5: Explain how health care policies affect patient-centered care.

Identify the potential impact of specific health care policy provisions on outcomes and patient experiences.

Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.

Raise awareness of the nurse’s vital role in the coordination and continuum of care in a video-recorded presentation. Script and reference list are not submitted.

Preparation

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.

Instructions

Presentation Format and Length

Create a detailed narrative script for your video presentation, approximately 45 pages in length. Include a reference list at the end of the script.

Supporting Evidence

Cite 35 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.

Grading Requirements

The requirements outlined below correspond to the grading criteria in the Care Coordination Presentation to Colleagues Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

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.

Fine tune the presentation to your audience.

Stay focused on key issues of import with respect to the effects of resources, ethics, and policy on the provision of high-quality, patient-centered care.

Adhere to presentation best practices.

Sample paper ( Please do not rewrite this paper)

Before we can begin a collaborative plan for patients, we must first have a clear understanding of what care coordination is. Care coordination is the process of helping health care consumers navigate safely and effectively through the fragmented and confusing health care environment (Janssen 2020). This produces the chance to ensure that patients are educated, adherent, and engaged in their own health. To be sucessful at care coordination, patiensts needs and preferences are recogniazed ahead of time and communicated at the right time to the right patient. The main goal of care coordination is to meet patientss needs and preferences in the delivery of high quality, high value health care. This means that the patients need, and preferences are known and communicated at the right time to the right people, and that this information is used to guide the delivery of safe, appropriate and effective care. 

Care coordination is a multi-facetted program that involves many components. First, the access to care and patients ability to obtain the care that is needed. Then the patient needs to be evaluated to establish what type of care is necessary. Then testing is done with diagnostics and consults. When the result are complied, a cae plan is created A care plan includes and education base to inform the patient on what is going on and what needs to be done to resolve it. Finally, there is the follow up that evaluates what is working and what needs to be changed. It is important that care coordination is a team that includes the patient, caregivers, and current healthcare providers working together to achieve the best outcomes.

    Elements of Coordinated Care 

There are four elements to care coordination; assess, diagnose, plan, implement and evaluate. First, the patient must have easy access to services and providers. Second, there requires communication and effective care plan transitions between providers. Third, a patient centered individualized plan is created focusing on their health care need for the plan to be in place. There elements appear to be simple and Stright forward, but there continues to be trials in standardization and barriers in communication among providers. Care coordination is a group effort. Success resides in the understanding that proper structure, available resources, guidance, and cultural support are needed for a multidisciplinary team to be effective.

Principles of Care Coordination 

We must understand the principle that tie care coordination together. Each care coordinated plan must be patient center based and personalized to each person. This requires an extensive permanence of care and involvement from all parties concerned.  In producing effective principles related to the individual outcomes of self-efficacy and cost effectiveness are utilized. It is important to assist in personalization the care and empowering the individual patient to be a part of their own self-management and follow-up care. (Loonen, Blijlevens, Prins, Dona, Hartogh, Senden, &Hermens,2018). Patient in connecting with their care a collaborative venture must be launched to put the patient at the hub of the care plan. Collaborative care plans must involve the combination of primary care, test results, community resources, medical history, and medication and treatment.

Step for Care Coordination

Care coordination takes in consideration the needs, values, and concerns of the patient while keeping in mind the goals of the care plan. This includes the medical history and treatment needs with multidisciplinary approach. Patients with chronic illness require a long-term routine that they must be a continual part of sharing of information must go both way for effective care coordination This includes the process of health screenings and prevention planning. Followed by an understanding of risk factors affecting health and wellness. (Loonen, a et al,2018). When all parties are on the same page a shared coordinated care plan is produced for successful patient centered care. Plans must be clear and concise to all parties involved with step-by-step planning and execution. Step by step planning gives room for modification and revision to uncover what is the best plan of care for the patients health management.

Care Coordination Based on Evidence Base Practice

In additiona to models, steps, elements, and principles there are other factors that affect care coordination when dealing with chronic conditions. There factors include and are not limited to deficits in noraml activity, social barriers, and  other health related factors that drastically effect care coordinated approaches. (Harschman, Shaid, McCauley, Pauly, & Naylor, 2015) Care coordination start when patients are discharged home or other long-term care facilities. As risks from the patients and care coordination team must be identified and join to educate and respond appropriately when needs arise. Continuity of care depends heavily on preventing breakdown in care and clinical involvement of all team members including care givers. This outcome connects effective healthcare and community base care. Evidence based outcomes demonstrate a decrease in readmissions and healthcare cost when effective care coordination interventions are accountable and realistic. It was determined in clinical evidenced base trials that and effective care coordination plan increase positive experience with care and quality of life. (Hirschman, Shaid, McCauley, Pauly, & Naylor,2015)

Communicating Care Coordination 

If patient and caregiver are not engaged with the healthcare team successful outcomes will not be realistic. Patients must feel as if they are a part of their care plan and their input is appreciated, important, and respected. Providers must make patients and care givers a portion of the team in every phase of care. Communication must be clear and education level appropriate for everyone to understand and collaborate increase understanding of the care plan, Continued follow-up and monitoring maintains communication for all issues as they arise. Everyone is responsible for the patients successful outcome. This increases decision-making and cooperation when revision is needed. Research shows a decline in health and continuity of care when there are preventable issues and tackle them to improve patient experience, improve health and reduce healthcare cost. (EL-Alti,Sandman,& Munthe, 2017).

Patient-Centered Care Coordination

The purpose of patient centered care is to coordinate team-base services and support with the patients exact needs. It is built on what matters to the patient and how the diagnosis affects them. An individualized plan contains goals, temporary management, and room for continuous development. Patient centered care takes into consideration racial and ethical diverse factor that directly affect team collaboration. It involves a community-based network of resources across the continuum of patient centered care. An effective patient centered coordinated care plan increases quality of life for patient and families. (Golden, Emery-Tiburcio, Post, Ewald, & Newman, 2019). Active listening, using simple understood communication, methods that empower patients, being approachable for questions, and continued encouragement for active engagement by the patient and their families is required for a plan to be successful. It is important to combine team of various professionals with single patient plan of care that is important to patients and families. To reach age specific and chronically ill patients it is essential that evidenced base research and training is done for effective team collaboration and understanding. Community outreach and support resources are equally as important in patient centered care plans. Continued communication with all disciplines is important and easily done through electronic systems to further collaborate care at every step and helps prevent breakdowns in plan of care. 

Affordable Healthcare Policies. 

Health care policies are effective when providers understand their roles and responsibilities of patient care. It is important for organizations to have consistent idea for healthcare outcomes and goals in the areas. It is vital to establish clear guidelines for effective care. Evidence shows that current policies impact healthcare by improving care to a better quality with realistic time frames of improvement and making it affordable for all income status individuals. (Kominski, Nonzee, & Sorensen, 2017) As we increase our methods of patient centered care collaboration we become more effective advocates in patients health outcomes. It has also been an ongoing issue of increased barriers for referrals to specialty care and other resources. Affordable Care Act (ACA) policies and provisions have made these needed resources more available for all patients increasing quality and quality of care. (Kominski, Nonzee, & Sorensen, 2017)

Nursing Roles.

With the evolution of cooperative collaborative coordinated care nursing roles continue to expand to better accommodate patient center care. Nurses provide changes in healthcare with team-based patient centered continuum care. By Increasing knowledge and skills about the changes in care they are better able to advocate for the betterment of their patients health and wellbeing. ( Salmond & Echevarria,2017) it is crucial for the nursing profession to contribute to improving patient care outcomes, quality and satisfaction as well as healthcare cost. Nurses accomplish this by providing safe efficient care. Creating a patient centered educational atmosphere that provides care in timely efficient equitable manner. (Salmond&Echevarria, 2017)


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