Care Coordination Presentation Narrative Script
Hello, and welcome to my video presentation on care coordination. My name is ….and I am a … nurse. Care coordination is a deliberate process. This process is systematic, organized, and involves collecting patient information and sharing this information with stakeholders that would positively impact patient care. Therefore, care coordination involves communication and collaboration with various professionals and personnel with an interest in the care of the patient.
Usually, we conduct care coordination at various points of change of patient care, such as admission, shift reporting, referrals, and follow-ups. During these periods, the responsibility of patient care changes from the outgoing care provider to the oncoming care provider.
Other processes that can run concurrently with care coordination are care planning, assessment, change management, and patient collaboration. In this video, I will discuss one strategy for patient collaboration, the relevant change management aspect, the importance of basing clinical decisions on ethics, and the implications of relevant policy provisions in care coordination
Engaging patients and their families in the care enhances the achievement of desired health outcomes. Their engagement in patient care increases adherence to health interventions and promotes patient-centered care. When a patient and their families are involved in the care, the barriers that exist between care providers and these stakeholders can be breached.
Patients and their families can be involved in their care through various strategies that include but are not limited to creating mutual trust, shared decision-making, and family support. Creating mutual trust between the patient or their families and the care providers increases their confidence in the care and chances of engaging in care activities.
This mutual trust can be created through various strategies such as personalized care planning, patient navigation, and shared decision-making. Personalized care planning, for example, incorporates the patient’s sociocultural and economic needs that make the care appropriate to the specific patient’s situation. Shared decision-making includes the patient in making the decision as the patient, or their families are consulted in clinical decisions.
A systematic review by Menear et al. in 2020 assessed various patient collaboration strategies in mental health settings. Shared decision-making was identified as a direct patient care strategy that incorporates clinical judgment, evidence-based practice, patient preferences, and patient values. Therefore, the final care decision is shared between the clinician’s input and the patient’s health determinants and wellbeing.
Family support strategies incorporate family consultation, communication with family, and partnership with family members to make shared decisions and ensure family-centered care. An example is when a patient with a chronic health condition is under home care, but according to the nurse’s judgment, the patient will require the utilization of community resources to reduce the risk of readmission and improve quality of life.
Therefore, the nurse can collaborate with the family to identify affordable, accessible, and sustainable community resources to aid the patient in coping with the disease. In so doing, the nurse would have provided family support through third-party involvement. This strategy will require care coordination through family collaboration and communication.
Change is inevitable. To improve is to change, and to be perfect is to change often. Change in care coordination is an expectable process, and a care coordinator needs to plan and preempt a change in patient care during this process. One of the critical aspects of change management that is relevant to care coordination is change communication.
Communicating change to the patients and their families can make them feel valued in the care process. Clear communication of change is an essential aspect of change that will improve patient experience because the patient will think about what matters to them, and these issues are addressed in the care according to an online article published by Zielinski & Rodriguez in 2018 on the Healthcare Financial Management Association website.
Change communication requires effective nurse knowledge, skills, and attitudes that enhance successful outcomes. Effective change communication must be timely so that patients and their families have adequate time to process the impact of the change. This consideration can improve patient satisfaction. Patient satisfaction scores are sometimes an objective method to assess patient care quality.
Ethics-based decision-making has been an integral part of nursing practice, both in clinical and administrative situations. At the basic level, decisions during care coordination should observe respect for patient autonomy, intend to do no harm to the patient, aim in the patient’s best interest, and be fair and just. The assumption is that these basic ethical principles can be applied differently without conflicts. The reality is that ethical dilemmas and ethical conflicts arise when these principles are used in decision-making.
In such situations, the code of ethics by the American nurse association in 2015 can apply to give directions. Utilization of the nine provisions in the code of ethics for nurses ensures that a nurse, during care coordination, adheres to policy and regulations of care. Ethical-based care plans are thus compliant with organizational and professional cultures and commitment to serving the patient’s interest.
Health policies regulate care coordination at the individual, organizational, and national levels. These policies are specific to certain settings, while other policies are general in care coordination. Some of the influential policies that regulate care coordination are the affordable care act, popularly known as Obamacare or ACA, the Health Insurance Portability and Accountability Act (HIPAA) which was enacted in 1996, and the Health Information Technology for Economic and Clinical Health Act also known as HITECH act of 2009.
HITECH policy has five key objectives that include increasing coordination of care, improving healthcare quality, efficiency, and safety, improving patient engagement, encouraging patient information security and privacy, and improving population health. This policy determines how healthcare professionals, especially coordinators of care, exchange information.
According to the HIPAA Journal website, this policy strengthened the HIPAA privacy and security rules to improve care coordination. The HIPAA policy of 1996 aims at keeping safe personal patient health information which is also known as protected health information or PHI. The affordable care act influences care coordination by encouraging patient access to information about the care-providing institutions.
This is a strategy to improve patient engagement in their care by having prior knowledge of the institutions to choose where to receive care. Most institutions are therefore required to share any shareable information about their care and policies to the public for patient consumption. This can improve the patient experience.
Finally, in my presentation, I would like to discuss the vital role that nurses have in care coordination and the continuum of care. According to the American Nurses Association website, the current paradigm shifts in care coordination highlight the relief that nurses have had after the government and healthcare system have stressed care coordination.
Hospitals, healthcare systems, and health insurance organizations rely on care coordination to improve patient health quality, patient experience, and satisfaction. Other players can benefit from well-coordinated care and providers of auxiliary services such as pharmacies, external laboratories, and community resources. The nurses have a vital role in ensuring well-coordinated care because they understand the patient and spend the most time with the patient in the clinical setting.
As the first clinical contact with the patient, nurses have an opportunity to understand the patient’s needs and preferences. Therefore, they get to understand what services and care professional the patient need and thus can appropriately coordinate this care.
According to the American Nurses Association website, nurses develop care plans that are guided by the needs and preferences of the patient, provide education to the patient and their families at discharge that include post-discharge coordination to community resources, and thereof ensuring that the care continues across the different settings. These roles are essential in care coordination and the care continuum.
In sum, care coordination should be systemic, planned, and deliberate. Care coordination is guided by ethics and policies and should be directed by patient needs and preferences to improve care quality by ensuring patient-centered care. Key policies that must be adhered to in most settings are HIPAA, HITECH, and ACA. The influential policies regulate patient information exchange and health information access to patients and third parties.
Nurses have to understand the ethical and policy underpinnings of care coordination because they have a vital role in well-coordinated care. Through patient education, care planning, and patient communication, nurses archive care coordination.
Thank you for following my presentation.
References
ANA. (2017, October 14). Care Coordination and the Essential Role of Nurses. ANA. https://www.nursingworld.org/practice-policy/health-policy/care-coordination/
HIPAA Journal. (2022, April 7). What is the HITECH Act? HIPAA Journal. https://www.hipaajournal.com/what-is-the-hitech-act/
Menear, M., Dugas, M., Careau, E., Chouinard, M.-C., Dogba, M. J., Gagnon, M.-P., Gervais, M., Gilbert, M., Houle, J., Kates, N., Knowles, S., Martin, N., Nease, D. E., Jr, Zomahoun, H. T. V., & Légaré, F. (2020). Strategies for engaging patients and families in collaborative care programs for depression and anxiety disorders: A systematic review. Journal of Affective Disorders, 263, 528–539. https://doi.org/10.1016/j.jad.2019.11.008
Zielinski, L., & Rodriguez, M. (2018, September 25). Change Management in Health Care: Navigating the Human Side of Successful Transitions. Hfma. https://www.hfma.org/topics/article/61970.html