Care Coordination Process
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Care Coordination Process
Introduction
To understand the care coordination process and the role of nursing in the coordination of care, we will first need to briefly understand the fundamental principles of care coordination, strategies for collaborating with patients for desired health outcomes, aspects of change management that directly affects elements of patient experience essential to the provision of high quality, patient-centered care, the rationale for coordinated care plans based on ethical decision making, and the potential impact of specific health care policy provisions on outcomes and patient experiences, as discussed below.
Fundamental Principles of Care Coordination
The main aim of coordination of care is to ensure the patients' preferences and needs are met. Therefore, achieving coordinated care can be by broad and specific approaches. Broad approaches include; teamwork, medication and care management, patient-centered medical home, and health information management. Specific care coordination includes; transitional care help, proactive plan creation, sharing knowledge, accountability and agreeing personality, follow-up and monitoring, having community resources link, supporting self-management goals of the patient, and aligning resources to population and patient needs (Care Coordination | Agency for Healthcare Research & Quality, 2018).
Strategies for Collaborating with Patients for Desired Health Outcomes
For effective patient and family management, family involvement is key to achieve desired health outcomes. In as much as patient-centered principles of care, coordination is great, real change effectiveness cannot be achieved if patients are not engaged in active roles. There are direct and indirect strategies for this engagement, to achieve the overarching goal desired to make behavioral changes in healthcare providers, administrators, patients, and family members. The behavior change techniques could be key family and patient involvement approaches. Baker and colleagues noted that engaging patients is grounded in the premise of patients possessing expertise by their own experiences. The patient's expertise is of benefit in reducing waste and cost, enhancing responsiveness to evolving needs of the user, and transparent decision making and quality improvement (Goodridge et al., 2018).
Direct involvement requires decision-making, like individual treatment decisions that have the following advantages: accountability and leadership, communication and teamwork, psychological safety, transparency, negotiation, and reliability. Indirect involvement includes gathering information from the public for service delivery in a collective manner without a role in decision making. This can provide a cultural composition on the perspective of illness and healthcare in the community to provide strategic plans (Goodridge et al., 2018).
We can also develop strategies in terms of direct care, organizational care, and policymaking. Direct care involves self-management supports, shared decision-making, personal medication access, and educating patients about treatment and illness. Organizational care includes; family support delivery, co-leadership to ensure safety and improved quality, peer support, and survey of patient's needs. Policymaking involves organizing policy groups with families and patients, co-leadership in policy finding decisions, and focus groups and survey to get public opinions (Menear et al., 2016).
Aspects of Change Management that Directly Affect Elements of Patient Experience Essential to the Provision of High-Quality, Patient-Centered Care
Change management is a critical element in healthcare. They include emotional aspects, cognitive aspects, physical aspects, and behavioral aspects. Characteristics of changes that are successful include the opportunity to influence change, preparing yourself for the change, then later valuing the change. Prior communication is also an essential element in the acceptability of change by the patients in healthcare. A reason for this is early preparation for change that increases the chances of success. Unexpected changes communicated by organizations is not fully supported by the patients as it raises various questions. The patients convey the need for understanding the benefits of organizational changes for success, especially with a patient focus. Other aspects include planning, evaluating, and implementing operations, tactics, and strategies for worthwhile and relevant change. Otherwise, the change would be complex, challenging, and dynamic. The changes in healthcare are encouraged if they promote quality and safety, or cost-benefit to patients, with marked improvement on the existing capabilities (Nilsen et al., 2020).
The five elements of patient experience include: caring, listening, explaining, teamwork and efficiency. The further explanation involves knowing, hearing, and teaching, coordinating with the patient and making it easy for the patient to understand different aspects of change management (The Five Elements of Patient Experience, 2018). Therefore, understanding the aspects of change management together with the elements of patient experience is quite helpful in care as it enables the patient to integrate behavioral, cognitive, physical, emotional, and physical as well as communication aspects impact patient experience when knowing, teaching, hearing, coordination, and explanation to the patient.
The Rationale for Coordinated Care Plans Based on Ethical Decision Making
Ethical considerations and coordinated care plans go hand in hand in influencing patient outcomes. The forces involved in ethical decision making include; good relationship with the patient, knowledge, and skills of the provider, and understanding of underlying principles of ethics, among others.
When coordinating care, ethical decision-making is mandatory. Shared decision-making between parties is of course a better outcome than if it was done individually, provided the ethical principles of autonomy, beneficence, justice, non-maleficence, and confidentiality remain mandatory. Therefore, for the success of the decision-making, ethical considerations are of importance. It should be noted that if principles of ethics like confidentiality are compromised, then the rationale for coordinated care is also compromised. Therefore, an ethical approach is essential for society to understand regulations and standards done by healthcare workers so that they can support their activities. Deontology and utilitarianism are some of the ethical principles in shared decision-making (Mandal et al., 2016).
Utilitarianism means that a professional makes a decision by predicting the outcomes of the actions they do and can be divided into rule and act utilitarianism. Rule utilitarianism is based on fairness and law despite the outcomes, while act utilitarianism is where the majority of the population benefits from the decision. Deontology is where decisions are concluded abide by their obligations and roles while making the decision (Mandal et al., 2016).
Therefore, understanding the ethical principles mentioned above helps when the care providers coordinate to provide better care outcomes.
The Potential Impact of Specific Health Care Policy Provisions on Outcomes and Patient Experiences
The potential impacts of specific provisions can be both positive and negative. The positive side includes health insurance that ensures coverage to most people if not all. The patients experience the enjoyment of decreased burden on the costs of healthcare. Citizens can pay via government initiative or privately to organizations that offer insurance coverage. If organizations are trustworthy, they can pay for the services, and the negative side is that they can fail to pay hence negative experiences among clients.
In general, different provisions have different impacts. For example, the Affordable care act has ensured that twenty million fewer Americans are uninsured, it protects people with pre-existing conditions from discrimination as insurers can no longer discriminate against people based on their health status, and healthcare has become more affordable for example, in 2019, eighty-seven percent of Americans enrolled and qualified for premium financial help while ensuring that all citizens are reached (Rapfogel et al., 2020).
Moreover, the Children’s health insurance program (CHIP) has ensured better experiences for younger patients as they are well enrolled and can even be covered under the insurance with little to negligible cost-sharing therefore boosting patient outcomes. Women’s health is also boosted by the fact that is charged less than before. Also, young adults have greater access to adolescent health coverage under the affordable care act. Medicaid has ensured expansion by allowing millions of individuals with low-income access to healthcare services hence better patient experiences. Lastly, seniors on Medicare have been lowered costs by the Affordable care act, therefore, boosting their health experiences (Rapfogel et al., 2020).
The Role of Nurses in Coordination and Continuum of Care
The continuum of care services includes community-based services, health information systems, disease management programs, and case management services. Therefore, nurses can directly impact health as they are a vital component in the coordination of care (The Sentinel Watch, 2020). In the modern world, there is an emphasis on the continuum of care that is very key in hospitals and care facilities. Therefore, health care providers play a vital role in follow-up care, while working towards smooth transitions. They play a vital role by assisting patients to think of their health as long term that directly involves them, their family, other medicals professionals, as well as their primary care physicians (The Sentinel Watch, 2020).
As a result, nurses need to specialize their management of cases relevant to their industry as they as key in working towards care plan transition. Healthcare will soon require professionals that can analyze the different technicalities in IT and bedside perspectives as Electronic Medical Records become a powerful integration system (The Sentinel Watch, 2020).
References
Care Coordination | Agency for Healthcare Research & Quality. (2018). Ahrq.gov. https://www.ahrq.gov/ncepcr/care/coordination.html
Goodridge, D., Henry, C., Watson, E., McDonald, M., New, L., Harrison, E. L., Scharf, M., Penz, E., Campbell, S., & Rotter, T. (2018). Structured approaches to promote patient and family engagement in treatment in acute care hospital settings: protocol for a systematic scoping review. Systematic Reviews, 7(1). https://doi.org/10.1186/s13643-018-0694-9
Mandal, J., Ponnambath, D., & Parija, S. (2016). Utilitarian and deontological ethics in medicine. Tropical Parasitology, 6(1), 5. https://doi.org/10.4103/2229-5070.175024
Menear, M., Gervais, M., Careau, E., Chouinard, M.-C., Cloutier, G., Delorme, A., Dogba, M. J., Dugas, M., Gagnon, M.-P., Gilbert, M., Harvey, D., Houle, J., Kates, N., Knowles, S., Martin, N., Nease, D., Pluye, P., Samson, E., Zomahoun, H. T. V., & Légaré, F. (2016). Strategies and impacts of patient and family engagement in collaborative mental healthcare: protocol for a systematic and realist review. BMJ Open, 6(9), e012949. https://doi.org/10.1136/bmjopen-2016-012949
Nilsen, P., Seing, I., Ericsson, C., Birken, S. A., & Schildmeijer, K. (2020). Characteristics of successful changes in health care organizations: an interview study with physicians, registered nurses, and assistant nurses. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-020-4999-8
Rapfogel, N., Gee, E., & Calsyn, M. (2020, March 23). 10 Ways the ACA Has Improved Health Care in the Past Decade. Center for American Progress. https://www.americanprogress.org/issues/healthcare/news/2020/03/23/482012/10-ways-aca-improved-health-care-past-decade/
The Five Elements of Patient Experience. (2018, September 7). Accelerate.uofuhealth.utah.edu. https://accelerate.uofuhealth.utah.edu/explore/the-five-elements-of-patient-experience
The Sentinel Watch. (2020, February 15). Different Nursing Roles in the Continuum of Care. The Sentinel Watch. https://www.americansentinel.edu/blog/2020/02/15/nursings-role-in-the-continuum-of-care/