NURS FPX 4065 Assessment 4

NURS FPX 4065 Assessment 4 Care Coordination Presentation to Colleagues

Student Name

Capella University

NURS-FPX4065 Patient-Centered Care Coordination

Prof. Name:

Date

Care Coordination Presentation to Colleagues

Care Coordination (CC) plays a central role in promoting patient-centered healthcare and ensuring smoother transitions across different care settings. It involves linking patients, families, and care teams to achieve better outcomes and provide continuous support (Karam et al., 2021). This presentation focuses on evidence-based practices that strengthen patient and family collaboration, improve the overall patient experience, and ensure that care decisions are ethically sound. Nurses remain at the heart of CC by advocating for safe, equitable, and effective treatment strategies.

Evidence-Based Strategies

Delivering coordinated care requires approaches that are both evidence-based and culturally appropriate.

Shared Decision-Making (SDM)

A key strategy is Shared Decision-Making (SDM), where patients and clinicians jointly decide on treatment plans. This approach tailors care to patients’ preferences and individual health circumstances. According to Resnicow et al. (2021), SDM should remain adaptable—some patients may require detailed guidance from healthcare providers, while others prefer more autonomy. Nurses support this process by using practical tools such as decision aids, plain-language explanations, and the teach-back method. These techniques increase patient understanding, boost confidence in decision-making, and strengthen autonomy—key elements in coordinated care.

Cultural Competence in Care

Cultural sensitivity also strengthens CC. Patients’ cultural beliefs, values, and linguistic preferences influence health decisions. The U.S. Department of Health and Human Services (HHS) emphasizes Culturally and Linguistically Appropriate Services (CLAS) standards, which guide healthcare professionals in ensuring inclusivity. Examples include providing translated educational materials, engaging interpreters, and involving family members in culturally respectful ways. These actions foster trust and improve communication, which are essential to reducing health disparities.

Family-Centered Care

Family involvement is particularly important for patients with chronic illnesses such as diabetes, cardiovascular disease, and asthma. Nurses educate families on treatment adherence, lifestyle changes, and community resources. When educational resources are culturally appropriate and aligned with patients’ literacy levels, families can effectively support patients at home, reducing complications and improving outcomes (Karam et al., 2021). Collaboration with community health workers further reinforces these benefits.

Change Management

Change management ensures that new strategies and policies are effectively implemented within CC. It is not only about restructuring systems but also about preparing frontline staff—especially nurses—to lead sustainable improvements.

Lewin’s Change Management Model

Lewin’s framework outlines three essential phases:

(Barrow, 2022)

This model ensures that improvements in CC are not temporary but embedded as standard practice.

Enhancing Patient Experiences Through Change

Patient experience improves when communication across transitions is consistent. Poorly managed handoffs may lead to errors, duplication of tests, or confusion regarding medications. To address this, nurse leaders adopt communication tools like SBAR (Situation, Background, Assessment, Recommendation) and begin discharge teaching well before the patient leaves the hospital. Furthermore, small yet impactful changes—such as timely follow-up calls, simplified scheduling, and real-time responses to patient concerns—can significantly improve patient satisfaction. These efforts demonstrate how managing incremental changes at the frontline can be more impactful than large-scale reforms (Barrow, 2022).

Rationale for Coordinated Care

CC in nursing practice is grounded in ethical principles such as autonomy, beneficence, and justice. The American Nurses Association (ANA, 2025) emphasizes that nurses are obligated to uphold dignity, protect patient rights, and provide compassionate care.

Ethical care involves:

• Respecting patients’ choices in treatment decisions.
• Incorporating families into long-term disease management.
• Addressing barriers such as language limitations or transportation challenges.

Using interpreter services, providing clear written instructions, and connecting patients to community programs are ethical practices that minimize disparities. According to Ilori et al. (2024), when nurses apply ethical decision-making frameworks, patient trust increases, moral distress decreases, and overall satisfaction improves. Ultimately, coordinated care ensures that patients’ values are central to every healthcare decision.

Impact of Health Care Policy Provisions

Healthcare policies greatly influence the effectiveness of CC.

Affordable Care Act (ACA)

The ACA expanded healthcare access by improving Medicaid coverage and mandating preventive care services. These provisions allow patients to receive early interventions and consistent disease management, thereby reducing hospitalizations. Furthermore, Accountable Care Organizations (ACOs) incentivize teamwork, where nurses are essential in patient education, follow-up, and care planning (Ercia, 2021).

HIPAA and Data Protection

The Health Insurance Portability and Accountability Act (HIPAA) regulates patient privacy. For nurses, HIPAA compliance ensures patients feel secure about their information, which strengthens trust. Respecting confidentiality allows nurses to share critical updates with the care team while maintaining patients’ rights. Mismanagement of privacy can lead to mistrust and reduced engagement.

Telehealth Expansion

Post-COVID-19 policy reforms have increased telehealth availability, helping underserved populations access care without geographic limitations. Nurses now provide virtual consultations, chronic disease monitoring, and medication education online. Studies confirm that telehealth enhances patient satisfaction and access (Moulaei et al., 2023). This technology strengthens CC by ensuring patients remain connected to healthcare providers regardless of distance.

Nurse’s Role in Coordination

Nurses act as the backbone of CC, facilitating smooth transitions and ensuring continuity across the healthcare system.

Key Contributions of Nurses

• Patient Education: Teaching self-care strategies, medication adherence, and preventive measures.
• Family Support: Guiding families in managing chronic conditions and providing lifestyle counseling.
• Team Communication: Updating care plans and coordinating across interdisciplinary teams.
• Policy Implementation: Driving initiatives such as value-based care models and Chronic Care Management (CCM) programs under CMS.

By taking on leadership roles, nurses reduce readmissions, enhance quality, and make care safer and more patient-focused (Karam et al., 2021).

Conclusion

Care Coordination ensures that healthcare delivery is patient-centered, efficient, and ethical. Nurses are central to this process, using evidence-based and culturally sensitive practices to support patients and families. Policies like the ACA, HIPAA, and telehealth reforms provide structural support for CC. Ethical principles guide practice, while change management ensures long-term sustainability. Together, these strategies empower nurses to lead improvements, enhance patient experiences, and create a stronger, more equitable healthcare system.

References

(kept as you provided, reformatted into APA 7th edition where needed)

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. National Library of Medicine; 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