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

Student Name

Capella University

NURS-FPX 6618 Leadership in Care Coordination

Prof. Name:


Purpose of Planning and Presenting a Care Coordination Project

This assessment focuses on developing a care coordination project plan for chronic care patients in the Virginia community. Elderly people in this community suffer from chronic diseases, resulting in higher comorbidities and mortalities. The quality of care provided to chronic disease patients lacks adequate coordination, leading to poor health outcomes in elderly patients. Hospital readmission rates are increasing daily due to poor management of chronic conditions like diabetes, hypertension, renal diseases, and chronic obstructive pulmonary disease.

Moreover, medication error rates are rising in chronic care patients due to a lack of coordination among healthcare professionals. As a care coordinator project manager at Sentara Northern Virginia Medical Center, I am developing a care coordination project plan for the described population, which requires care coordination from multiple organizations. This care coordination plan will help the elderly population with chronic conditions manage their condition with a coordinated and patient-centered care approach.

Vision of Interagency Coordinated Care for Chronic Care Patients

The primary vision of interagency coordinated care for chronic care patients is patient-centered and collaborative care, prioritizing the overall well-being of the elderly population with chronic conditions. This is possible by integrating a multidisciplinary team of healthcare professionals, including physicians, nurses, pharmacists, social workers, dietitians, etc. The care coordinating teams will enable effective care delivery through adequate coordination and collaboration, leaving no room for errors or treatment delays.

Effective sharing of patient health data among healthcare professionals is necessary. This can be done using healthcare technologies such as electronic health records, which enhance smooth coordination and communication as they can be integrated into multiple organizations (Southerland et al., 2020). A patient-centered care approach can be delivered in several ways, from onsite follow-ups to online consultations via telehealth technology. By leveraging technology, healthcare providers can give consolidated care remotely, and patients can receive coordinated care in the comfort of their homes.

Furthermore, patient-centered care clinics can be established for this population, serving as a central point for chronic patients. This will provide consolidated care to chronic care patients from physical, mental, and emotional perspectives (Corazzini et al., 2019). Additionally, healthcare professionals must be provided with ongoing training and educational programs to gain the necessary skills and knowledge to deliver consolidated care with improved quality to treat chronic conditions. This will pave a constant roadway for healthcare professionals to provide continuity of care for chronic care patients.

Underlying Assumptions and Areas of Uncertainty

The underlying assumption of this vision is that healthcare professionals can overcome barriers to collaboration and eradicate fragmented care by working together and coordinating care in the best interest of patients. Moreover, with advancements in healthcare technologies, healthcare professionals can share patient data and enable care coordination. The trained healthcare workforce can find better ways to provide consolidated care. However, uncertainties in fulfilling this vision pertain to various factors, such as stagnant behaviors of patients, inadequate healthcare teams, resource limitations, and interoperability challenges (Gunnarson, 2022). These areas of uncertainty must be considered while developing and implementing a care coordination plan for the affected population.

Mandatory Organizations and Groups to Participate in Care

Several organizations and groups must participate to provide consolidated and holistic care for chronic disease patients. These identified organizations that must contribute to improving coordinated care for chronic patients include “Virginia’s Department of Health,” “Virginia’s Association of Area Agencies on Aging,” and national healthcare organizations such as the “American Heart Association (AHA),” “American Diabetes Association (ADA),” and “American Nursing Association (ANA).” The Virginia Department of Health advocates for the prosperity of public health, including care for chronic patients. They have worked on various initiatives to prevent chronic diseases and manage them effectively (Virginia Department of Health, n.d.).

Therefore, their vital participation can promote coordinated care among chronic disease patients. Likewise, Virginia’s Association of Area Agencies on Aging is a widespread network of agencies in Virginia that work for chronic diseases among elderly people and promote healthy aging. This organizational group can provide their services in delivering coordinated care for patients with chronic conditions. Moreover, national healthcare organizations like AHA and ADA provide guidelines on coordinated care for managing heart diseases and diabetes, respectively, which are commonly prevalent among elderly people. Lastly, the ANA must participate in care for this population group as nurses are inherently care coordinators and collaborate with other healthcare professionals in delivering coordinated care to patients. Therefore, they can actively provide consolidated care to elderly patients in managing their chronic conditions.

Identified Members of Interprofessional Care Coordination Team

The interprofessional care coordination team must comprise primary care physicians, nurses, pharmacists, social workers, dietitians, case managers, telehealth specialists, community health workers, health educators, and mental health specialists. These team members will collaborate and provide concerted care to chronic disease patients (Khatri et al., 2023). The primary care physicians will develop patient care plans with pharmacists and nurses. Mental health specialists will ensure elderly patients are mentally well by providing them with mental health services and counseling.

The social and community health workers will address social determinants of health for these patients and connect them with community resources. The dietitians will provide nutrition counseling for patients requiring lifestyle modifications. The case manager will oversee care transitions, ensure seamless communication, and manage the overall initiative for delivering coordinated care to the affected population. Lastly, telehealth specialists will ensure steady remote consultations by facilitating telemedicine and remote monitoring services. These team members will be able to provide coordinated care with effective planning.

Analysis of Environmental and Provider Capabilities

Considering the insightful and comprehensive analysis of environmental and provider capabilities, several factors impact care coordination for chronic care patients. Factors like healthcare policy and regulations on data sharing and telehealth regulations impact the environmental ability to provide adequate coordinated care. Moreover, the availability of funding and reimbursement, technology infrastructure, and public health literacy are primary environmental factors that may hinder care coordination. Additionally, the provider capabilities, including interprofessional team attitudes towards collaborating with other team members, are significant factors impacting consolidated care delivery. Furthermore, access to advanced health information technology, trained care coordinators, practical communication skills, and cultural competency are significant provider capabilities that ensure potent coordinated care (Khatri et al., 2023).

Determining Resource Needs of the Population

The resources needed for delivering coordinated care to chronic care patients depend on several factors, such as the number of patients, the level of care required, the type of chronic disease being managed, and the healthcare facility’s size and capabilities. However, the approximate resource needs of this population must include general supplies, staffing, capital purchases, and funds to procure these resources. Considering the assumptions and uncertainties that may be encountered while providing coordinated care, the resources required can be as follows:

General Supplies

Assuming the central part of the chronic care patient population comprises diabetics, hypertension patients, and chronic respiratory patients, the general supplies required will include medications for these specific diseases, equipment for measuring blood glucose levels, oxygen levels, and blood pressure, wound dressings, catheters, bandages, and syringes. Other supplies include office supplies for administrative tasks. The estimated annual costs for these supplies will be $75,000 for a moderately sized healthcare facility. The uncertainties may include a lack of knowledge of the number of patients, supply demands, and fluctuating costs for these supplies. Considering these uncertainties, the budget may require adjustments in the future.


Considering the healthcare setting operates on a standard 40-hour workweek and patient-to-provider ratios following industry standards, the staff requirements will be at least two primary care physicians, four registered nurses, and one pharmacist. Additionally, one care coordinator and two medical assistants will be required. Furthermore, mental health specialists, healthcare information technologists, and administrative staff for recording, billing, and front-desk personnel will be essential for smooth care coordination. The annual costs for the workforce are estimated to be $1,025,000. The uncertainties about staffing include unknown patient volume, staff turnover rates, and staffing availability.

Capital Purchase

Assuming the moderate-sized healthcare setting and no previous existing infrastructure, several capital purchases will be necessary. This will include healthcare information technology, office infrastructure, and transportation in terms of one-vehicle purchase and operational costs. The estimated costs will be $470,000. Moreover, the costs and estimated funds include $15,000 for operating expenses such as rent, insurance, and maintenance. Additionally, training and education funds have estimated annual costs of $20,000, and emergency preparedness and response funds are estimated at $10,000 annually. Considering these supplies, capital purchases, staffing, and operational costs, the estimated annual budget for this chronic care facility will be $1,615,000 annually. This budget is projected annually to facilitate long-term planning and resource allocation. However, the budget might need adjustments based on patient needs, emerging healthcare trends, and regulation changes to coordinate high-quality care.

Project Milestones and Outcome Measures

Attaining goals for the care coordination plan project will include several key steps: stakeholder engagement, resource allocation, program designing and establishment, staffing and training, care planning and coordinating, and continuous monitoring and improvement. Each of these milestones will be achieved within a specified timeframe. The organization will discuss the goals and objectives of this project with relevant stakeholders, which include the need to provide care coordination to chronic care patients. This is expected to take two months. After a thorough discourse on this subject, the next milestone of resource allocation will be achieved within three to six months, where resources will be acquired and allocated equitably.

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

Next, the collaborative design of the program will be executed, and a program for providing coordinated care will be established within six months. Next, one-month training of health professionals will result in well-trained experts in care coordination. This training will help the team members effectively collaborate strategically. Once the training is conducted, healthcare professionals will develop and implement care coordination plans by delivering the best quality coordinated and consolidated care. This phase is slated to last three months and will be followed by ongoing monitoring and evaluation (Miller et al., 2019).

Outcome Measure for Care Coordination Project

The outcome measures identified for this project include

clinical health outcomes, which can be measured by finding disease-specific clinical indicators such as HbA1c levels for diabetes and blood pressure and cholesterol levels for cardiovascular diseases. Additionally, patient medication adherence can be measured by measuring the percentages of patients consistently taking their medication as directed. Furthermore, assessing changes in symptom severity and frequency of chronic care conditions such as pain levels, shortness of breath, and fatigue will gauge the quality of care provided and the achievement of project goals.

Another outcome measure is healthcare utilization, where hospital readmission rates for chronic disease patients can be measured for thirty days to assess the quality of care. Moreover, patient satisfaction surveys can be conducted to assess patient perceptions and their overall experience of this project. This will assist healthcare professionals in estimating the quality of care delivered to patients and driving improvements to match results with desired goals (Conway et al., 2019).

Presentation of Project Plan to Administrative Decision-Makers

For the successful implementation of care coordination for chronic care patients, it is imperative to integrate a patient-centered care approach with multidisciplinary collaboration. This requires equitable resource allocation and engagement with relevant stakeholders. The milestones will be achieved within the allocated timelines with coherent collaboration. Multiple organizations will participate in this project for financial aid and coordinated care delivery. The project outcome measures will be evaluated from time to time to ensure desired goals are achieved.


A care coordination project for chronic care patients is essential as fragmented care results in poor health outcomes, including reduced quality of life, comorbidities, and increased death rates. Moreover, lack of care coordination can lead to higher medication and treatment errors in chronic disease patients, further aggravating poor quality of health. Therefore, this care coordination plan project is developed for chronic care patients. The vision of interagency coordinated care is to provide a patient-centered approach and collaborative care. “Virginia’s Department of Health,” “Virginia’s Association of Area Agencies on Aging,” and national healthcare organizations such as the “American Heart Association (AHA),” “American Diabetes Association (ADA),” and “American Nursing Association (ANA)” must participate in care for the affected population.

The resource needs vary based on fluctuating factors but require a $1,615,000 annual cost for general supplies, staffing, and capital purchases. Several project milestones are identified, from stakeholder engagement to establishing coordinating plans and implementing care coordination. The outcome measures include hospital readmission rates, patient satisfaction, and clinical health outcomes.


Conway, A., O’Donnell, C., & Yates, P. (2019). The effectiveness of the nurse care coordinator role on patient-reported and health service outcomes: A systematic review. Evaluation & the Health Professions, 42(3), 263–296. https://doi.org/10.1177/0163278717734610

Corazzini, K. N., Anderson, R. A., Bowers, B. J., Chu, C. H., Edvardsson, D., Fagertun, A., Gordon, A. L., Leung, A. Y. M., McGilton, K. S., Meyer, J. E., Siegel, E. O., Thompson, R., Wang, J., Wei, S., Wu, B., & Lepore, M. J. (2019). Toward common data elements for international research in long-term care homes: Advancing person-centered care. Journal of the American Medical Directors Association, 20(5), 598–603. https://doi.org/10.1016/j.jamda.2019.01.123

Gunnarson, M. (2022). Disclosing the person in renal care coordination: Why unpredictability, uncertainty, and irreversibility are inherent in person-centred care. Medicine, Health Care and Philosophy, 25https://doi.org/10.1007/s11019-022-10113-z

Khatri, R., Aklilu Endalamaw, Erku, D., Eskinder Wolka, Frehiwot Nigatu, Zewdie, A., & Assefa, Y. (2023). Continuity and care coordination of primary health care: A scoping review. BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-09718-8

Miller, L. B., Sjoberg, H., Mayberry, A., McCreight, M. S., Ayele, R. A., & Battaglia, C. (2019). The advanced care coordination program: A protocol for improving transitions of care for dual-use veterans from community emergency departments back to the Veterans Health Administration (VA) primary care. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-4582-3

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

Southerland, L. T., Stephens, J. A., Carpenter, C. R., Mion, L. C., Moffatt-Bruce, S. D., Zachman, A., Hill, M., & Caterino, J. M. (2020). Study protocol for IMAGE: Implementing multidisciplinary assessments for geriatric patients in an emergency department observation unit, a hybrid effectiveness/implementation study using the consolidated framework for implementation research. Implementation Science Communications, 1(1). https://doi.org/10.1186/s43058-020-00015-7

Virginia Department of Health. (n.d.). Chronic disease prevention and health promotion collaborative. https://www.vdh.virginia.gov/collaborative/

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