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 achieving better patient outcomes and ensuring seamless delivery of healthcare services. Nurses act as the connecting link between patients, families, and multidisciplinary teams, offering continuous support throughout the care process (Karam et al., 2021). This presentation highlights evidence-based practices for collaboration with patients and families, while also emphasizing ethical decision-making and improving patient experiences. Nurses remain central to patient-focused care, and CC ensures that treatment is equitable, safe, and efficient.

Evidence-Based Strategies

Shared Decision-Making (SDM)

One of the most effective strategies in CC is Shared Decision-Making (SDM). This approach involves patients and healthcare providers jointly making informed treatment decisions. Resnicow et al. (2021) explain that SDM must be flexible and responsive to the unique needs of patients—some may prefer more provider input, while others want to be more actively involved. Nurses can foster SDM by employing decision aids, plain-language communication, and the teach-back method to ensure patients understand their options and feel confident in managing their health.

Cultural Competence

Culturally responsive care is equally important. Patients’ beliefs, values, and traditions significantly influence their health choices. The U.S. Department of Health and Human Services (HHS) provides national standards to support care for Culturally and Linguistically Diverse (CALD) populations. These standards encourage equity and inclusivity. For instance, offering education in a patient’s primary language and involving family members in care discussions enhances trust and communication. Nurses who apply culturally sensitive practices reduce health disparities and build strong community partnerships.

Family Engagement

Family participation is essential, particularly for chronic illnesses such as asthma, heart failure, or diabetes. Nurses guide families in understanding care plans, medication management, and lifestyle modifications. When families receive health education tailored to literacy levels and cultural backgrounds, they can actively support the patient at home. Collaborating with community health workers further strengthens this education and leads to improved long-term health outcomes (Karam et al., 2021).

Summary of Evidence-Based Strategies

Strategy	Description	Outcome
Shared Decision-Making	Collaboration between patients and providers in treatment decisions	Promotes patient autonomy and informed choices
Cultural Competence	Incorporating patients’ cultural, linguistic, and traditional perspectives	Builds trust, reduces disparities, and supports inclusive care
Family Involvement	Educating and empowering families to support patient care	Prevents complications, supports chronic care, and improves outcomes

Change Management

Change management in CC goes beyond policies—it is about preparing nurses and frontline staff to lead sustainable improvements in patient care. One significant challenge is maintaining clear communication during care transitions, as fragmented communication can cause medication errors, repeated tests, or overlooked instructions.

Lewin’s Change Management Model

Lewin’s model (Barrow, 2022) provides a structured framework for guiding change:

Phase	Nursing Role	Expected Impact
Unfreezing	Identifying the need for change and preparing the care team	Creates awareness and readiness
Changing	Implementing new care processes and evaluating feasibility	Promotes innovation and adaptation
Refreezing	Standardizing new practices as organizational norms	Ensures sustainability and consistency

Enhancing Patient Experience Through Change

To improve patient experiences, nurses use standardized tools like SBAR (Situation, Background, Assessment, Recommendation) and initiate discharge teaching early. Unlike older systems focused only on survey data, modern CC emphasizes real patient experiences—such as effective pain management, timely responses, and clear instructions. Small but impactful improvements, like simplifying appointment scheduling or providing follow-up calls, enhance trust and reduce dissatisfaction (Barrow, 2022).

Rationale for Coordinated Care

Coordinated care must be guided by ethical principles, ensuring justice, respect, and safety for all patients. According to the American Nurses Association (ANA, 2025), nurses are ethically obligated to advocate for patients’ rights while delivering compassionate, patient-centered care.

Key ethical values in CC include:

• Autonomy: Respecting patients’ choices in care decisions.
• Beneficence: Acting in the patient’s best interest.
• Justice: Ensuring fair access to resources and treatments.

Addressing barriers such as transportation challenges, health literacy, and language differences is also part of ethical care. Using interpreter services, providing community referrals, and offering clear discharge instructions reduce risks and enhance compliance. By adopting SDM and cultural competence, nurses not only improve patient outcomes but also minimize ethical conflicts and moral distress in their practice (Ilori et al., 2024).

Impact of Health Care Policy Provisions

Health care policies directly influence CC and patient outcomes.

Affordable Care Act (ACA)

The ACA has broadened access to healthcare by expanding Medicaid and mandating coverage for preventive services (Ercia, 2021). It also supports Accountable Care Organizations (ACOs) that encourage collaborative practice. Nurses, as part of ACOs, educate patients, conduct follow-ups, and bridge care gaps, reducing hospital readmissions.

HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) safeguards patient privacy. By complying with HIPAA, nurses build trust while sharing vital information with healthcare teams. Maintaining confidentiality enhances patient engagement and ensures they feel secure during the care process.

Telehealth Expansion

The COVID-19 pandemic accelerated telehealth policies, improving access to care, especially for rural and underserved populations. Nurses use telehealth platforms to monitor symptoms, guide patients, and manage chronic conditions, thereby maintaining continuity of care (Moulaei et al., 2023).

Nurse’s Role in Coordination

Nurses are central to ensuring continuity of care across healthcare settings. Their responsibilities include:

• Educating patients and families about medications and self-care.
• Assessing ongoing needs and adjusting care plans in collaboration with teams.
• Managing transitions between hospitals, primary care, and home.

Policy reforms such as value-based care models and the CMS Chronic Care Management (CCM) initiative further expand nurses’ roles. These initiatives emphasize quality over quantity, positioning nurses as leaders in discharge planning, community referrals, and long-term follow-ups (Karam et al., 2021). When nurses are empowered to coordinate care, outcomes improve, costs reduce, and patient trust deepens.

Conclusion

Effective care coordination enhances patient safety, satisfaction, and engagement. Nurses, at the forefront, bridge care transitions, guide families, and apply evidence-based and culturally sensitive practices. Supported by policies like the ACA and HIPAA, as well as ethical standards, coordinated care ensures that treatment remains patient-centered and equitable. Ultimately, CC strengthens healthcare systems, reduces errors, and fosters better long-term outcomes.

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 on 1226 patients. BMC Medical Informatics and Decision Making, 23(1). https://doi.org/10.1186/s12911-023-02348-4

NURS FPX 4065 Assessment 4 Care Coordination Presentation to Colleagues

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