NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project
NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project
Name
Capella university
NURS-FPX 6618 Leadership in Care Coordination
Prof. Name
Date
Planning and Presenting a Care Coordination Plan
Greetings, everyone. My name is __, and I am excited to present a comprehensive care coordination strategy designed for individuals with chronic care needs. As the Care Coordination Project Manager, my primary goal is to ensure these patients receive optimal care. This presentation will outline the key components of this holistic plan and emphasize its importance in addressing the healthcare challenges faced by chronic care patients.
Purpose of Care Coordination Plan
Managing chronic conditions involves significant challenges, and a new approach is emerging: a care coordination project tailored for chronic care patients. This initiative seeks to address fragmented care by uniting healthcare providers, specialists, and support services. Given the complexity of chronic illnesses, which require a personalized and holistic approach, this project is both necessary and highly beneficial (Hardman et al., 2020). By integrating resources, communication networks, and specialized expertise, the plan holds the potential to transform chronic care delivery. The following sections will explore its critical importance, complexities, and far-reaching impact for those managing chronic conditions.
Vision for Interagency Coordinated Care
The vision for interagency coordinated care for chronic care patients focuses on delivering seamless, comprehensive, and patient-centered services across multiple organizations. The aim is to foster collaboration among healthcare providers, social service agencies, community organizations, and other stakeholders to effectively address the complex needs of chronic care patients. This model emphasizes creating a robust network where various agencies work cohesively to provide care tailored to each patient’s individual needs, preferences, and goals (Hunter et al., 2023).
In this vision, integrated care delivery unites healthcare services, social support, and community resources to create a continuous, seamless care experience. By breaking down barriers among providers, such as hospitals and community organizations, the model promotes an effective approach to coordinated care (Hunter et al., 2023). A centralized hub for care coordination is essential for managing patient journeys, enabling effective communication among patients, caregivers, and service providers (Hardman et al., 2020). Additionally, leveraging technology, such as electronic health records (EHRs), telehealth, and data analytics, enhances information sharing, facilitating proactive interventions (Northwood et al., 2022).
| Key Aspect | Details | References |
|---|---|---|
| Purpose of Care Coordination | Addresses fragmented care by uniting healthcare providers, specialists, and support services. | Hardman et al., 2020 |
| Vision for Interagency Coordinated Care | Ensures seamless, patient-centered care across various organizations, emphasizing collaboration. | Hunter et al., 2023 |
| Technology Integration | Uses EHRs, telehealth, and data analytics to improve care coordination and proactive interventions. | Northwood et al., 2022 |
Assumptions and Uncertainties
The vision for coordinated care for chronic care patients rests on several assumptions, including the essential need for seamless communication and collaboration among various agencies. Furthermore, patient empowerment and engagement are seen as critical to effective care delivery. Sufficient resources must be available to implement and sustain this initiative, with flexibility to adapt to the evolving needs of patients and the challenges within the healthcare system (Kendzerska et al., 2021). However, uncertainties regarding the long-term sustainability of these collaborative efforts remain, especially due to funding constraints and shifting healthcare priorities. Issues related to patient participation, data sharing, and interoperability among systems present ongoing challenges. Additionally, changes in healthcare policies and regulations may impact care delivery and funding, necessitating continuous evaluation and adjustments to the coordinated care model (Kendzerska et al., 2021).
Identifying the Organizations and Groups
Caring for chronic care patients requires a collaborative approach involving various organizations at local, state, and national levels. At the local level, primary care clinics, hospitals, home health agencies, and community organizations play essential roles. These organizations work together to manage both acute and chronic health needs and provide vital social support (Gizaw et al., 2022).
At the state level, state health departments, Medicaid offices, and professional organizations are crucial for coordinating resources and ensuring compliance with regulations (Centers for Medicare & Medicaid Services, 2021). Nationally, organizations such as the Centers for Medicare & Medicaid Services (CMS) and professional bodies like the American Nurses Association (ANA) and the American Medical Association (AMA) help shape coordinated care initiatives through advocacy and policy development (American Nurses Association, 2023; Centers for Medicare & Medicaid Services, 2021).
| Level | Key Organizations | Role |
|---|---|---|
| Local Level | Primary Care Clinics, Hospitals, Home Health Agencies, Community Organizations | Provide initial care, handle acute situations, and offer social support to address health determinants. |
| State Level | State Health Departments, Medicaid Offices, Medical Associations | Coordinate resources, policies, and professional guidance, and address financial aspects of care. |
| National Level | Centers for Medicare & Medicaid Services (CMS), ANA, AMA | Align care coordination with federal policies and provide standards, guidelines, and advocacy. |
References
American Diabetes Association. (2022). ADA. Diabetes.org. https://diabetes.org/
American Nurses Association. (2023). American nurses association. ANA Enterprise. https://www.nursingworld.org/
Centers for Medicare & Medicaid Services. (2021, March 22). Medicaid home | Medicaid.gov. Medicaid.gov. https://www.medicaid.gov/
Chakurian, D., & Popejoy, L. (2021). Utilizing the care coordination Atlas as a framework: An integrative review of transitional care models. International Journal of Care Coordination, 24(2), 57–71. https://doi.org/10.1177/20534345211001615
Devi, R., Goodman, C., Dalkin, S., Bate, A., Wright, J., Jones, L., & Spilsbury, K. (2020). Attracting, recruiting and retaining nurses and care workers working in care homes: The need for a nuanced understanding informed by evidence and theory. Age and Ageing, 50(1), 65–67. https://doi.org/10.1093/ageing/afaa109
Farley, H. (2020). Promoting self‐efficacy in patients with chronic disease beyond traditional education: A literature review. Nursing Open, 7(1), 30–41. https://doi.org/10.1002/nop2.382
NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project
Gizaw, Z., Astale, T., & Kassie, G. M. (2022). What improves access to primary healthcare services in rural communities? A systematic review. BioMed Central Primary Care, 23(1). https://doi.org/10.1186/s12875-022-01919-0
Hardman, R., Begg, S., & Spelten, E. (2020). What impact do chronic disease self-management support interventions have on health inequity gaps related to socioeconomic status: A systematic review. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-020-5010-4
Hunter, P. V., Ward, H. A., & Puurveen, G. (2023). Trust as a key measure of quality and safety after the restriction of family contact in Canadian long-term care settings during the COVID-19 pandemic. Health Policy, 128, 18–27. https://doi.org/10.1016/j.healthpol.2022.12.009
Kendzerska, T., Zhu, D. T., Gershon, A. S., Edwards, J. D., Peixoto, C., Robillard, R., & Kendall, C. E. (2021). The effects of the health system response to the COVID-19 pandemic on chronic disease management: A narrative review. Risk Management and Healthcare Policy, 14, 575–584. https://doi.org/10.2147/rmhp.s293471
NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project
Northwood, M., Shah, A. Q., Abeygunawardena, C., Garnett, A., & Schumacher, C. (2022). Care coordination of older adults with diabetes: A scoping review. Canadian Journal of Diabetes, 47(3), 272–286. https://doi.org/10.1016/j.jcjd.2022.11.004
Sikander, S., Biswas, P., & Kulkarni, P. (2023). Recent advancements in telemedicine: Surgical, diagnostic, and consultation devices. Biomedical Engineering Advances, 6. https://doi.org/10.1016/j.bea.2023.100096