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. I am pleased to introduce a comprehensive care coordination initiative specifically designed for individuals managing chronic health conditions. As the Care Coordination Project Manager, my chief responsibility is to optimize patient outcomes by fostering collaborative, patient-centered care models. This presentation will cover essential components of a coordinated care strategy, highlighting its role in addressing the unique and complex challenges faced by patients with chronic illnesses.

Purpose of Care Coordination Plan

Managing chronic conditions often involves fragmented care, leading to gaps in service and unmet patient needs. In response, a structured care coordination project has been formulated to unite healthcare providers, specialists, and ancillary services under a cohesive framework. The primary aim is to bridge these divides, ensuring a continuous and holistic approach tailored to each patient’s health profile (Hardman et al., 2020). By integrating multidisciplinary expertise, efficient communication pathways, and supportive resources, this initiative promises to transform chronic care management into a more seamless and impactful process. The following sections will elaborate on the strategic importance, operational complexities, and broad-reaching effects of this intervention for individuals navigating long-term health conditions.

Vision for Interagency Coordinated Care

Collaborative Goals for Chronic Care Delivery

The vision for interagency care coordination prioritizes comprehensive, integrated, and patient-focused services delivered through collaboration among healthcare systems, community organizations, and support agencies. This initiative aims to establish a robust, interconnected network that can effectively respond to the complex and evolving needs of patients with chronic illnesses (Hunter et al., 2023). Central to this vision is aligning services and resources to accommodate patients’ physical, emotional, and social well-being while respecting individual preferences and health goals.

Integrated Service Delivery Model

A seamless continuum of care requires dismantling barriers between hospitals, clinics, community-based programs, and social services. The plan advocates for a centralized coordination hub to serve as the primary communication and management point, ensuring that all involved parties operate in alignment (Hardman et al., 2020). Developing individualized care plans through interdisciplinary collaboration allows for the effective addressing of interconnected medical, psychological, and social needs.

Technological Integration and Innovation

Advanced digital tools such as electronic health records (EHRs), telehealth services, and data analytics platforms will support this interagency vision by improving information sharing and enabling timely, proactive care interventions. These technologies help streamline care coordination efforts, enhance decision-making, and foster continuous patient monitoring (Northwood et al., 2022).

Assumptions and Uncertainties

Operational Assumptions

Key assumptions underlying the care coordination vision include the necessity of effective interagency communication, patient engagement, and adequate resource availability. The program’s success also hinges on the healthcare system’s flexibility to adapt to emerging patient needs and the dynamic nature of chronic disease management (Kendzerska et al., 2021).

Uncertainties and Constraints

Despite these foundational premises, several uncertainties persist. Long-term sustainability may be threatened by inconsistent funding, workforce shortages, and evolving healthcare regulations. Additionally, achieving seamless data sharing and interoperability across different healthcare systems remains a significant challenge. These uncertainties necessitate continuous program evaluation and adaptability to maintain care quality and service continuity (Kendzerska et al., 2021).

Identifying the Organizations and Groups

Providing comprehensive care for chronic care patients requires coordinated efforts across local, state, and national entities. The table below outlines the key organizations and groups involved at each level:

Table 1: Organizations Involved in Care Coordination

Level	Organizations/Groups	Roles
Local	Primary care clinics, hospitals, home health agencies, community organizations	Patient management, acute care, home services, social support
State	State health departments, Medicaid offices, medical/nursing boards, advocacy groups	Resource coordination, policy guidance, patient-centric advocacy
National	CMS, ANA, AMA, disease-specific organizations like ADA	Federal policy alignment, professional standards, specialized resources

(Gizaw et al., 2022; Centers for Medicare & Medicaid Services, 2021; American Nurses Association, 2023; American Diabetes Association, 2022)

Interprofessional Care Coordination Team

A diverse, interprofessional team forms the backbone of this care coordination initiative. Primary care physicians oversee treatment plans and service integration, while nurses and nurse practitioners provide continuous patient education and health monitoring. Social workers focus on addressing social determinants of health and connecting patients with community services. Pharmacists manage complex medication regimens, reducing adverse interactions and improving adherence.

Additionally, care coordinators act as liaisons among patients, providers, and services, ensuring fluid care transitions. Health information technologists enhance data exchange through EHR systems, while community health workers foster engagement and health literacy within local populations (Kendzerska et al., 2021).

Environment and Provider Capabilities

A thorough analysis of the healthcare environment reveals varied capabilities among providers, influenced by socioeconomic disparities, geographic limitations, and infrastructure differences. Local healthcare systems often face workforce shortages and technological gaps, while state and national systems provide essential policy frameworks and funding resources (Gizaw et al., 2022). The opportunity lies in leveraging existing provider strengths while addressing gaps through policy reforms, technological innovations, and interagency collaborations.

Determining the Resource Needs of the Population

Accurate resource planning for chronic care patients requires assessing operational supplies, staffing, and capital infrastructure.

Table 2: Resource Categories and Projected Costs

Resource Category	Details	Estimated Costs (Annual)
General Supplies	Medications, wound care, telehealth tools, office supplies	\$50,000 – \$100,000
Staffing	Physicians, nurses, social workers, care coordinators, administrative staff	\$500,000 – \$1,000,000
Capital Purchases	EHR systems, telemedicine equipment, mobility aids, facility upgrades	\$100,000 – \$500,000

(Sikander et al., 2023; Devi et al., 2020)

Assumptions, Uncertainties, and Inferences

Assumptions

Resource estimates presume regular supply replenishment, cost variability, competitive salaries, and continuous training opportunities. Additionally, capital investments include ongoing maintenance and upgrades to comply with industry standards (Gizaw et al., 2022; Farley, 2019).

Uncertainties

Operational challenges include fluctuating patient caseloads, reimbursement variability, staffing shortages, and potential regulatory changes (Devi et al., 2020). Evolving technology needs and unpredictable healthcare policy shifts further contribute to systemic uncertainties.

Inferences

Adaptive planning, such as flexible budgeting, scalable technology investments, and staff cross-training, is necessary for operational resilience. Strengthening community partnerships can help buffer financial and personnel constraints, enhancing care coordination reliability (Kendzerska et al., 2021).

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Project Milestones

The project will unfold across distinct phases:

1. Development of Care Coordination Plan (3–4 months): This phase involves stakeholder collaboration to draft comprehensive care strategies, workflows, and communication protocols tailored for chronic care management (Chakurian & Popejoy, 2021).

2. Implementation of Care Coordination Strategies (5–8 months): Activities include launching interdisciplinary meetings, patient education initiatives, and staff training programs while integrating technological tools to streamline care processes (Gizaw et al., 2022).

3. Monitoring and Evaluation: The final phase will focus on assessing program effectiveness through patient outcomes, operational efficiency, and stakeholder feedback to refine the care coordination model further.

References

American Diabetes Association. (2022). Standards of medical care in diabetes—2022. https://doi.org/10.2337/dc22-S001

American Nurses Association. (2023). Nursing: Scope and standards of practice (4th ed.). ANA.

Centers for Medicare & Medicaid Services. (2021). Chronic care management services. https://www.cms.gov

NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project

Chakurian, C., & Popejoy, L. (2021). Care coordination models: A review. Journal of Nursing Care Quality, 36(1), 67–73. https://doi.org/10.1097/NCQ.0000000000000499

Devi, R., et al. (2020). Effective staffing models for chronic care management. BMC Health Services Research, 20(1), 12. https://doi.org/10.1186/s12913-020-06091-7

Farley, R. L. (2019). Financial considerations in health care delivery. Health Care Management Review, 44(2), 109–116.

Gizaw, A., et al. (2022). Healthcare system performance in managing chronic diseases. BMC Public Health, 22(1), 2255. https://doi.org/10.1186/s12889-022-14543-4

Hardman, T., et al. (2020). Integrated care pathways for chronic disease management. Journal of Integrated Care, 28(2), 151–162. https://doi.org/10.1108/JICA-08-2019-0038

Hunter, C., et al. (2023). Interagency collaboration in healthcare. International Journal of Health Policy and Management, 12(1), 23–34.

Kendzerska, T., et al. (2021). Challenges in care coordination for chronic conditions. Health Affairs, 40(1), 76–84. https://doi.org/10.1377/hlthaff.2020.01562

NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project

Northwood, M., et al. (2022). Technology in care coordination. Journal of Medical Internet Research, 24(5), e32701. https://doi.org/10.2196/32701

Sikander, S., et al. (2023). Budgeting strategies in chronic care services. Healthcare Financial Management, 77(3), 44–50.