NURS FPX 4065 Assessment 4 Care Coordination Presentation to Colleagues

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Capella university

NURS-FPX4065 Patient-Centered Care Coordination

Prof. Name

Date

Care Coordination Presentation to Colleagues

Care Coordination (CC) plays a central role in achieving better patient outcomes and ensuring smooth healthcare delivery. It allows nurses to act as a vital link between patients, families, and healthcare teams by promoting consistent communication and ongoing support (Karam et al., 2021). This presentation emphasizes evidence-based methods that encourage collaboration with patients and families, strengthen ethical decision-making, and improve overall care experiences. Nurses remain at the core of CC, ensuring that care is equitable, holistic, and patient-centered.

Evidence-Based Strategies

Shared Decision-Making (SDM)

One effective evidence-based strategy is Shared Decision-Making (SDM), where nurses and patients work together to evaluate treatment choices. According to Resnicow et al. (2021), SDM allows patients to actively participate in their care while also accommodating individual needs. For some patients, more professional guidance is necessary, while others prefer greater independence in decision-making. Nurses support SDM by employing decision aids, plain language communication, and the teach-back method to ensure patient understanding. These approaches enhance autonomy, increase confidence, and strengthen trust in the healthcare system.

Cultural Competence

Cultural sensitivity is another foundation of CC. Nurses must acknowledge how cultural norms, traditional practices, and language differences affect patient behaviors and expectations. The U.S. Department of Health and Human Services (HHS) provides national standards to help healthcare providers meet the needs of Culturally and Linguistically Diverse (CALD) groups. Practical steps include:

Cultural Competence Practice	Example Application
Use of interpreter services	Translating discharge instructions into a patient’s preferred language
Family involvement	Allowing family members to participate in care planning
Culturally tailored education	Providing nutrition education aligned with cultural dietary habits

When nurses integrate such culturally appropriate practices, they help reduce disparities and build stronger patient-provider relationships.

Family Involvement

Family engagement is vital, especially for chronic illnesses such as diabetes, asthma, and heart disease. Nurses teach families about medication adherence, symptom monitoring, and available community resources. With health literacy-friendly educational materials, families can better support self-care practices at home. Collaborating with community health workers also reinforces patient and family education, leading to improved long-term outcomes (Karam et al., 2021).

Change Management

Lewin’s Change Management Model

Change management within CC is not solely about introducing new procedures—it is about equipping nurses to sustain improvements that directly affect patients. Lewin’s Change Model includes three key phases (Barrow, 2022):

Phase	Description	Nursing Application
Unfreezing	Identifying the need for change and preparing staff	Nurses acknowledge challenges in discharge planning and build team awareness
Changing	Implementing and experimenting with new processes	Adopting standardized discharge tools and team-based care models
Refreezing	Making the changes permanent	Embedding SBAR communication into everyday practice

Through these stages, nurses become proactive leaders in driving sustainable improvements.

Enhancing Patient Experience

Patient experiences improve when transitions between care settings are consistent and safe. Poorly coordinated handoffs can lead to medication errors, unnecessary readmissions, or duplicated tests. To address this, nurses use SBAR communication tools, early discharge education, and real-time follow-up calls. Even small adjustments—like simplifying appointment scheduling or minimizing response delays—can build more trust than large-scale reforms. This patient-centered approach shows how effective change management contributes to positive healthcare experiences.

Rationale for Coordinated Care

Coordinated care should always align with ethical values such as justice, beneficence, and respect for patient autonomy. The American Nurses Association (ANA) Code of Ethics highlights the nurse’s duty to protect patient dignity while promoting safe, empathetic, and individualized care (ANA, 2025).

Ethical nursing practices include:

• Encouraging patient involvement in decisions.
• Respecting cultural differences and personal preferences.
• Using interpreter services for patients with limited English proficiency.
• Addressing social determinants of health, such as transportation barriers.

Ethical CC builds patient trust, reduces conflicts during care transitions, and ensures decisions are consistent with patient values. According to Ilori et al. (2024), ethical decision-making also reduces nurse moral distress, promotes professional confidence, and strengthens communication in the healthcare setting.

Impact of Health Care Policy Provisions

Healthcare policies shape how nurses coordinate care and address patient needs.

Affordable Care Act (ACA)

The ACA expanded access to care by broadening Medicaid coverage and mandating insurance for preventive services. This enables patients to receive early interventions, avoid costly hospitalizations, and manage chronic illnesses effectively (Ercia, 2021). ACA-driven Accountable Care Organizations (ACOs) also encourage interprofessional teamwork, where nurses contribute by coordinating follow-ups, educating patients, and reducing communication gaps.

Health Insurance Portability and Accountability Act (HIPAA)

HIPAA protects patient privacy and sets standards for secure information sharing. When nurses adhere to these standards, patients feel respected and more willing to disclose sensitive information. Trust is essential for effective CC, and HIPAA provides the framework to maintain that trust.

Telehealth Expansion

The COVID-19 pandemic accelerated the adoption of telehealth policies, improving access for rural and underserved populations. As Moulaei et al. (2023) explain, telemedicine has enhanced patient satisfaction by allowing virtual check-ins, medication monitoring, and chronic disease management without travel barriers. Nurses now use telehealth to provide symptom monitoring, patient education, and real-time consultations, strengthening CC across the care continuum.

Nurse’s Role in Coordination

Nurses act as key coordinators across the healthcare system. Their responsibilities include:

• Educating patients and families about medications, self-care, and lifestyle management.
• Ensuring safe transitions between hospitals, rehabilitation centers, and home care.
• Monitoring patients’ progress and updating care plans with interdisciplinary teams.
• Leading initiatives like CMS Chronic Care Management (CCM) to support patients with multiple chronic illnesses.

Value-based healthcare models further highlight the nurse’s central role, rewarding providers not for the quantity but for the quality of care. This shift empowers nurses to take leadership in managing discharges, conducting follow-up calls, and ensuring continuity across diverse settings (Karam et al., 2021).

Conclusion

Care Coordination (CC) is essential for improving patient safety, satisfaction, and outcomes. By applying evidence-based strategies such as SDM, cultural competence, and family involvement, nurses foster patient-centered care. Change management models guide the implementation of sustainable improvements, while ethical principles ensure care aligns with patient dignity and values. Healthcare policies such as the ACA, HIPAA, and telehealth regulations expand the nurse’s ability to coordinate care. Ultimately, nurses remain the backbone of CC—bridging systems, empowering patients, and shaping a healthcare system that is equitable and responsive.

References

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. 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