Care Coordination Presentation

Good afternoon, everyone! My name is ____________, and I am a registered nurse here at UMass Memorial. Care Coordination is an essential practice of primary care that employs nurses to bridge the gap between the patients, their families, and the healthcare team for a safer patient care practice. Nurses design more effective care plans to improve the health outcomes of the patients and coordinate such plans among the health care team and other concerned people for the coordination and continuity of care. Nurses are obligated to implement a continuum of care that follows an ethical framework and consumes all the resources optimally for the welfare of patients. This presentation aims to raise nurses' understanding of the fundamental principles of care coordination and ethical decision-making while implementing effective strategies for patient-centered care.

Effective Strategies for Collaborating with Patients

Patient care involves a team-based care plan that includes collaborating with medical care staff and the patient's family members. The agenda is to raise awareness about the disease among all the concerned people. All the nursing staff members, health professionals, specialists, paramedic staff, the patient's family, and the patient himself should be part of this team. The main aim of this team-based care plan is the availability of effective and safer care to the patients (Poitras et al, 2018). The agency presents two main strategies that might prove helpful for better outcomes. Both strategies involve collaboration with patients' families.

The first strategy comprises wider approaches, including team-based care that involves all the concerned people in the health care department for patient-centered care, reconciling medication to ensure better patients outcomes, a coordinated care administration, use of Information technology that creates better communication among the health care facilitators and patients thus promoting the quality of care.

The second strategy following particular care coordination involves designing a coordinated care plan for the patients, allowing proper communication and education of the patients, determining the patient's requirements and reaching health goals, assisting with care transition, implementing proper monitoring and follow up plans, promoting patients’ health goals and including community resources into the plan.

As indicated by the researchers at Johns Hopkins University, nurse-guided primary care has improved the health outcomes for community organizations. This model involves a specially educated nurse. The nurse takes a preliminary assessment of the patient, collaborates with other health care facilitators, determines the patients' needs, involves the health specialist, and follows a highly coordinated care plan (Haas et al., 2019). Guided care can save up to 11% on total health care expenses and limit hospital re-admissions, thus providing safe, effective, and inexpensive care to the patients.

Change Management and Patient-Centered Care

The health care team needs to make changes in health management to ensure the patients' involvement in their health care plan. They are supposed to guide the patients properly about the disease and advise them on specific adjustments to improve their health. The health care providers used to apply facts and logic, insisting the patients follow a health care plan which was usually ignored on the part of the patients (Bergerum et al., 2019). This was followed by a reprimand being repeated by the physician. This tactic never worked in improving the health of the patients. The need is to change the attitude of the whole care management and care plan. The research has shown that instead of arguing or forcing the patients to follow the health care plan, it is needed to go for more patient-centered approaches. Health professionals should question the patients to think of ways of improving their health and make a plan themselves, assess the barriers encompassing their ways, and suggest a more appropriate and suitable plan (Poitras et al, 2018). This tactic has paved the path to achieving health care goals.

Care coordination and guided care plan have brought positive changes to the health care system. Making the patients a part of their team and transmitting essential knowledge to the patients enhances the patient's involvement. This increases the patients’ satisfaction and guarantees effective care provision to them (Chen et al., 2020). Coordinated care planning has been shown to improve the quality of care.

Ethical Decision Making and Coordinated Care Plans

Nurses are supposed to have complete knowledge of ethical principles to impact patient care from the ethical aspect. A nurse having a better understanding of ethical decision-making can influence the health care team accordingly. A nurse must keep a balance between autonomy and beneficence for the establishment of an effective care plan. The aim is to respect the patients' rights and allow them to make decisions on their own regarding their treatment (Bergerum et al., 2019). The ethical care coordination plan demands the active involvement of the patients. Moreover, the American Nurses Association Code of Ethics directs the nurses to speak for the patients' rights. Nurses stand for the patients in the execution of the care plan and advocate for their rights even if it goes against the opinions of other team members.

Cultural aspects are also considered in the ethical care coordination plan. Cultural sensitivity and acceptance are one of the evidence-based practices that help understand how different patients belonging to different cultures behave in particular situations. This involves complete acquaintance of other cultures and acceptance on the side of the health care provider (Bergerum et al., 2019). Such behavior provides a peaceful environment for effective care. Understanding about patient's culture enables healthcare facilitators to adopt a better healthcare approach for the patient. They can console them well in case of any gloomy situation and guide them about the next plan of action. Respecting other cultures is important. It creates a sense of acceptance and rapport among the patients and health care providers. Nurses must have a basic understanding of how different cultures interact to avoid any dynamic misinterpretation.

Healthcare Policy Provisions on Outcomes and Patient Experiences

“Patient Protection and Affordable Care Act has played a significant role in improving the health care system” (Chen et al., 2020). Research shows that following Affordable care act policies facilitate patients. Patients would have greater access to a coordinated care plan, facilitate continuity of effective care and limit re-admissions if the health care policies are put in action effectively. It's been researched that countries with coordinated care plans and proper health management systems have better patient outcomes and save the health budget for other welfare (Chen et al., 2020). Taking preventive measures before the health problems worsen and following after-care precautions can reduce the mortality rate and lower re-admissions of treated patients. This can reduce the burden on the health care departments, and they can focus on the smaller number of patients more attentively.


A vital part is played by the nurses in care coordination and continuum of care. Patient-centered care plan based on patients' preferences and needs results in better patient outcomes. Along with the awareness of health care policies, nurses must be culturally competent. They must have a better acquaintance with other cultures. This allows them to provide effective treatment to patients belonging to diverse backgrounds having different cultures and social values. This impacts the nurse's care coordination plan keeping ethical aspects into consideration. The nurses should allow patients to make decisions about treatments and choose the most suitable care plan. Nurses are supposed to educate the patients about the disease and possible adjustments they can bring in their routine plan to cope with the pertaining illness. They should avoid dictating them. Instead, they should involve them in making a carefully coordinated plan that suits their routine and is easy to follow.


Bergerum, C., Thor, J., Josefsson, K., & Wolmesjö, M. (2019). How might patient involvement in healthcare quality improvement efforts work—a realist literature review. Health Expectations, 22(5), 952–964.

Chen, C.-C., & Cheng, S.-H. (2020). Care continuity and care coordination: A preliminary examination of their effects on hospitalization. Medical Care Research and Review, 78(5), 475–489.

Haas, S., Swan, B. A., & Jessie, A. T. (2019). Care coordination: Roles of registered nurses across the care continuum. Nursing Economics, 37(6), 317–322.

Poitras, M.-E., Maltais, M.-E., Bestard-Denommé, L., Stewart, M., & Fortin, M. (2018). What are the effective elements in patient-centered and multimorbidity care? a scoping review. BMC Health Services Research, 18(1).

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