NURS FPX 4065 Assessment 4 Care Coordination Presentation to Colleagues

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Capella university

NURS-FPX4065 Patient-Centered Care Coordination

Prof. Name

Date

Care Coordination Presentation to Colleagues

Care Coordination (CC) plays a vital role in enhancing patient outcomes and ensuring smooth healthcare delivery across different settings. Nurses act as the connecting link between patients, families, and healthcare teams, fostering communication and continuity of care (Karam et al., 2021). This presentation highlights evidence-based strategies that strengthen collaboration with patients and families, promote positive experiences, and ensure ethically sound care. Nurses remain at the forefront of patient-centered approaches, and CC enables fair, safe, and effective treatment across diverse populations.

Evidence-Based Strategies

Shared Decision-Making

One of the central evidence-based practices in CC is Shared Decision-Making (SDM). This process allows patients and providers to work together when choosing treatment plans. According to Resnicow et al. (2021), SDM requires flexibility since patients differ in how much guidance they need from healthcare providers. Nurses can support SDM by applying practical tools such as:

Strategy	Nursing Role	Patient Impact
Decision aids	Guide patients through treatment choices	Improves clarity and understanding
Teach-back method	Ensure patients can repeat care instructions	Reduces errors and builds confidence
Plain language communication	Simplify medical information	Enhances autonomy and engagement

These methods not only foster patient independence but also encourage them to be active participants in their care journey.

Cultural Competence in Care

Cultural competence is another key factor in effective CC. Nurses must be aware of how cultural traditions, beliefs, and language barriers influence patients’ healthcare behaviors. The U.S. Department of Health and Human Services (HHS) has established standards for addressing the needs of Culturally and Linguistically Diverse (CALD) groups, ensuring equity in healthcare delivery. Examples include:

• Offering medical instructions and educational materials in a patient’s native language.
• Including family members in care planning when cultural norms require collective decision-making.
• Collaborating with community leaders to increase patient trust in medical interventions.

By tailoring care to cultural values, nurses reduce disparities and foster stronger patient-provider relationships.

Family-Centered Approaches

Family involvement is especially important for patients with chronic conditions such as diabetes, heart failure, or asthma. Nurses can empower families by teaching them disease management, self-care techniques, and preventive strategies. When families receive culturally relevant and easy-to-understand education materials, they can provide consistent support at home, reducing complications and hospital readmissions (Karam et al., 2021). Collaboration with community health workers further enhances the sustainability of this education.

Change Management

Applying Lewin’s Model

Change management in CC is about preparing healthcare teams, especially nurses, to lead improvements that directly benefit patients. Lewin’s Change Model consists of three stages:

Phase	Description	Nursing Application
Unfreezing	Recognizing the need for change	Identify gaps in transitions and prepare staff
Changing	Implementing new practices	Introduce team care models and revise discharge protocols
Refreezing	Embedding the new norm	Ensure permanent adoption through policies and training

This model enables nurses to lead change with confidence while maintaining patient safety (Barrow, 2022).

Improving Patient Transitions

One of the most frequent problems during transitions is poor communication, leading to missed instructions, medication errors, and repeated diagnostic tests. To address this, nurses use tools like SBAR (Situation, Background, Assessment, Recommendation) and provide discharge instructions early in the care process. Unlike older models that focused on satisfaction surveys alone, coordinated care now considers patients’ lived experiences—such as clarity of instructions, pain control, and responsiveness of providers.

Small but impactful changes—like simplifying scheduling systems, reducing call-back delays, and ensuring follow-up calls—have been shown to enhance trust and satisfaction more effectively than large organizational overhauls.

Rationale for Coordinated Care

Coordinated care is grounded in ethical nursing values that emphasize justice, safety, respect, and dignity. The American Nurses Association (ANA) Code of Ethics obliges nurses to safeguard patient rights while providing compassionate, evidence-based care (ANA, 2025).

Key ethical principles in CC include:

• Autonomy: Respecting patients’ decisions and preferences.
• Beneficence: Promoting actions that maximize patient well-being.
• Justice: Ensuring fairness in access and treatment.

Nurses address barriers such as transportation challenges and language differences by arranging interpreter services, providing accessible discharge instructions, and connecting patients with community resources. Such strategies promote patient compliance, minimize errors, and align care with personal values (Ilori et al., 2024).

Ethical decision-making also strengthens trust, reduces conflicts, and builds integrity in nursing practice. Nurses feel more confident and less morally distressed when guided by clear ethical frameworks.

Impact of Health Care Policy Provisions

Affordable Care Act (ACA)

The ACA has transformed healthcare access by expanding Medicaid, requiring coverage for preventive services, and supporting Accountable Care Organizations (ACOs). These changes have allowed more patients to receive care earlier, reducing hospitalizations and improving chronic disease management (Ercia, 2021). Nurses in ACOs coordinate discharge planning, provide patient education, and ensure effective follow-up.

HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) provides patients with privacy protection. For nurses, HIPAA ensures secure communication while maintaining patient trust. Clear boundaries in data sharing promote respect, encourage patient openness, and enhance coordinated care efforts.

Telehealth Policies

Following the COVID-19 pandemic, telehealth policies expanded access to care, especially for patients in rural or underserved areas. Nurses now use telehealth for remote symptom monitoring, medication support, and chronic disease follow-ups. This model increases accessibility and strengthens the nurse-patient relationship (Moulaei et al., 2023).

Nurse’s Role in Coordination

Nurses are the backbone of CC, ensuring patients transition smoothly across care settings. Their responsibilities include:

• Educating patients and families on medications, diet, and self-care.
• Communicating with multidisciplinary teams to update care plans.
• Preventing hospital readmissions by arranging timely follow-ups.
• Advocating for patient needs in policy and care planning.

Policy initiatives, such as value-based care models and the CMS Chronic Care Management (CCM) program, place nurses at the center of coordinated efforts. These programs not only improve patient health outcomes but also reduce costs by supporting long-term, nurse-led interventions (Karam et al., 2021).

Conclusion

Care coordination ensures safer, more effective, and patient-centered care. Nurses serve as leaders in managing transitions and applying evidence-based strategies that enhance quality outcomes. Change management frameworks support sustainable improvements. Ethical principles ensure dignity and autonomy, while policies like the ACA, HIPAA, and telehealth reforms expand access and trust. Ultimately, effective CC empowers patients, strengthens families, and positions nurses as vital advocates within an evolving healthcare system.

References

ANA. (2025). Ethics and human rights. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/

Barrow, J. M., & Annamaraju, P. (2022). Change management in health care. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459380/

Ercia, A. (2021). The impact of the Affordable Care Act on patient coverage and access to care: Perspectives from FQHC administrators in Arizona, California and Texas. BMC Health Services Research, 21(1), 1–9. https://doi.org/10.1186/s12913-021-06961-9

NURS FPX 4065 Assessment 4 Care Coordination Presentation to Colleagues

Ilori, O., Kolawole, O., & Aderonke, J. (2024). Ethical dilemmas in healthcare management: A comprehensive review. International Medical Science Research Journal, 4(6), 703–725. https://doi.org/10.51594/imsrj.v4i6.1251

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), 1–21. https://doi.org/10.5334/ijic.5518

Moulaei, K., Sheikhtaheri, A., Fatehi, F., Yazdani, A., & Bahaadinbeigy, K. (2023). Patients’ perspectives and preferences toward telemedicine versus in-person visits: A mixed-methods study. BMC Medical Informatics and Decision Making, 23(1). https://doi.org/10.1186/s12911-023-02348-4

Resnicow, K., Catley, D., Goggin, K., Hawley, S., & Williams, G. C. (2021). Shared decision making in health care: Theoretical perspectives for why it works and for whom. Medical Decision Making, 42(6), 755–764. https://doi.org/10.1177/0272989×211058068