NURS FPX 4065 Assessment 4 Care Coordination Presentation to Colleagues

Name

Capella university

NURS-FPX4065 Patient-Centered Care Coordination

Prof. Name

Date

Care Coordination Presentation to Colleagues

Care coordination (CC) is a structured process designed to ensure patients experience smooth transitions, holistic support, and improved health outcomes. Nurses are at the center of this framework, linking patients, families, and interdisciplinary teams to foster continuity of care and reduce fragmentation (Karam et al., 2021).

This assessment highlights evidence-based methods for patient and family collaboration, explores strategies that enrich patient experiences, and underscores the importance of ethical practices in decision-making. Through CC, healthcare organizations provide equitable, safe, and patient-centered treatment, thereby advancing quality across the continuum of care.

Evidence-Based Strategies

Delivering coordinated care requires interventions that are evidence-based, culturally sensitive, and patient-inclusive.

Shared Decision-Making (SDM)

A central evidence-based method is Shared Decision-Making (SDM), in which patients actively participate in making informed treatment choices alongside healthcare professionals. Resnicow et al. (2021) argue that SDM must be adaptable to individual health contexts—patients with complex conditions may need more structured guidance, while others may prefer autonomy. Nurses facilitate SDM through:

Nursing Strategies for SDM – Decision aids to explain treatment options; Teach-back methods to confirm understanding; Plain language communication to reduce medical jargon.

These approaches promote autonomy, strengthen patient engagement, and improve confidence in managing care.

Cultural Competence in Care Coordination

Equally important is cultural competence. Patients’ values, beliefs, and language affect how they perceive and accept care. National standards, such as those by the U.S. Department of Health and Human Services (HHS), promote culturally and linguistically appropriate services for diverse populations. Examples include offering medical education materials in a patient’s preferred language, involving family members in decisions, and employing interpreters to reduce miscommunication. By addressing cultural and linguistic needs, nurses reduce health disparities and build trust.

Family Involvement

Family engagement is a cornerstone of CC, especially for chronic diseases such as asthma, diabetes, and cardiovascular disorders. Nurses provide tailored education, coaching, and community referrals that empower families to support patients effectively at home (Karam et al., 2021). Culturally relevant, literacy-adjusted materials allow families to reinforce care practices, ultimately lowering risks of complications.

Change Management

The Role of Change in Coordinated Care

Change management within CC equips frontline workers, particularly nurses, to champion patient-centered improvements. A significant challenge lies in achieving consistent communication across transitions, as poor handoffs often cause errors, duplications, or misunderstandings.

Lewin’s Change Management Model provides a structured framework:

Stages of Change and Nursing Role – Unfreezing: recognizing the need for change and preparing the team; Changing: implementing and testing new practices; Refreezing: standardizing updates to ensure sustainability.

Improving Patient Experience Through Change

Patient experiences improve when transitions are seamless and instructions are clear. Nurses employ tools such as SBAR (Situation, Background, Assessment, Recommendation) and early discharge education to prevent confusion. Unlike earlier models that focused mainly on satisfaction surveys, modern CC emphasizes tangible patient experiences such as pain management, timely communication, and clarity of instructions.

Small yet meaningful changes, such as reducing wait times or offering same-day follow-up calls, significantly increase patient trust. These micro-level reforms can be more impactful than sweeping organizational changes (Barrow, 2022).

Rationale for Coordinated Care

Ethics remain the backbone of CC. According to the American Nurses Association (ANA) Code of Ethics, nurses are responsible for promoting justice, safety, and dignity in care (ANA, 2025).

How Ethical Principles Apply to Coordinated Care – Autonomy: involving patients and families in chronic disease planning; Beneficence: providing accurate information for informed choices; Justice: addressing barriers like transportation or language limitations.

For instance, interpreter services and community referrals reduce inequities and enhance adherence. Furthermore, ethical decision-making reduces moral distress among nurses while improving trust and communication with patients (Ilori et al., 2024).

Impact of Health Care Policy Provisions

Healthcare policies directly shape how nurses coordinate and deliver care.

Affordable Care Act (ACA)

The ACA expanded Medicaid, increased insurance coverage, and emphasized preventive care. By supporting Accountable Care Organizations (ACOs), the ACA promotes collaboration among providers. Nurses in ACOs manage follow-ups, patient education, and care planning to reduce gaps and avoid readmissions (Ercia, 2021).

HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) ensures confidentiality. Patients who feel their privacy is protected are more likely to trust providers. Nurses apply HIPAA guidelines to share critical updates with teams while safeguarding sensitive information.

Telehealth Policies

Post-COVID-19, telehealth expansion has improved access for rural and underserved populations. Nurses now provide virtual monitoring, medication support, and education, ensuring continuity of care outside hospitals. Telehealth enhances flexibility, reduces travel barriers, and fosters ongoing patient-provider communication (Moulaei et al., 2023).

Nurse’s Role in Coordination

Nurses act as navigators in the healthcare journey, ensuring patients receive continuous, organized, and person-centered care across multiple settings. Their responsibilities include teaching self-care, promoting medication adherence, coordinating with multidisciplinary teams, and revising care plans as conditions evolve.

Policies such as value-based care models and the CMS Chronic Care Management (CCM) initiative recognize the critical role of nurses in achieving cost-efficient, high-quality outcomes. When empowered, nurses lead discharge planning, organize community referrals, and implement follow-up systems that enhance both safety and satisfaction (Karam et al., 2021).

Conclusion

Care coordination strengthens patient safety, engagement, and satisfaction. Nurses are vital in bridging care settings and guiding patients with evidence-based, ethical, and culturally sensitive strategies. Policies like the ACA, HIPAA, and telehealth initiatives expand nurses’ roles, enabling them to deliver equitable, patient-centered care. Ultimately, CC fosters collaboration, reduces errors, and ensures patients are treated with dignity and respect—contributing to a stronger, more responsive healthcare system.

References

American Nurses Association. (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/

NURS FPX 4065 Assessment 4 Care Coordination Presentation to Colleagues

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

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