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Capella 4050 Assessment 3

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    Capella 4050 Assessment 3

    Capella 4050 Assessment 3 Care Coordination Presentation to Colleagues

    Student Name

    Capella University

    NURS-FPX 4050 Coord Patient-Centered Care

    Prof. Name


    Care Coordination Presentation for Colleagues

    Hello everyone, I am ………. and today we will talk about care coordination and its role in healthcare systems in our presentation. To start with this topic, it is important that we understand what coordination of care is. According to the Agency for Healthcare Research and Quality (AHRQ), care coordination is defined as “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services”. Millions of people across the globe have complex diseases and demand appropriate care for improving their health.

    Care coordination for these patients is the utmost need of the hour.  In care coordination, patients are provided with the most coordinated and collaborative care by the help of healthcare professionals. It involves integrated care to improve the care maintenance, accessibility to multiple medical resources, effective communication for quality and safety of care, as well as cost effectiveness of services so that seamless and comprehensive care can be provided to patients. Provision of treatment and medication through teamwork is important for successful outcomes in patients’ health. (Karam et al., 2020).

    Effective Strategies for Coordination

    For the desired care coordination, there should be some effective strategies that need to be implemented. These strategies will be important in provision of improved care management and ensuring patient safety and quality of care. Care coordination can be achieved by collaboration of nurses, physicians, patients and their families and with other healthcare professionals. Culturally and linguistically diverse patients (CLDP) get little access to healthcare services than the host populations and are faced with different obstacles such as organization and complexity of healthcare systems, access to certain health services, legal prohibitions, and also relates to the individual barriers such as low health literacy, employment status, fear of the stigma, language barriers, and differences in health beliefs.

    Organizations such as the United Nations and WHO prohibit health inequity, as they consider health to be a fundamental right of every individual (World Health Care, 2021). In order to diminish these differences, the improvement of cultural competence in healthcare organizations has to be done.The implementation of cultural competence in healthcare services is the strategy to tackle all these disparities. Cultural competency is the set of certain behaviors, and attitudes that are practiced in a system of professionals that ensures the professionals work effectively in cross-cultural situations.

    Capella 4050 Assessment 3

    There are multiple strategies for providing access to culturally competent healthcare which are as follows:

    • Integration of community health workers (CHW) to educate patients during home or clinic visits (Oikarainen et al., 2019).
    • Use of telemedicine to overcome language barriers by a bilingual or multilingual physician and nurse to improve the quality of life (Handtke et al., 2019)
    • Creating community health networks to improve healthcare by exchanging information with other institutions within a community to share patient’s health (Brottman et al., 2020).

    Healthcare professionals should always respect the uniqueness of each family system and their cultural values and beliefs. For example, some families include their extended family members or clans composed of many households’ of relatives in a family-based support network and others just consider the immediate family to be in the family-centered care coordination. Nurses and other healthcare professionals can develop a personalized relationship with families and communicate in culturally appropriate ways.

    Healthcare systems should recruit staff who consider diversity as an asset and they should create alliances with the cultural guides. By creating a culturally competent environment for patients with cultural diversity, health betterment can be obtained and nurses can play a vital role in achieving this goal. It is important that all healthcare coordinate with nurses to ensure the appropriate care provided to the patient in all healthcare systems.

    Aspects of Change Management

    Change management is something that takes plenty of time and when change management is required to take place in a healthcare setup, it is enigmatic and demands smart steps to follow. Implementation of an evidence-based strategy can prove to be helpful in finding medical problems and planning solutions that will facilitate patient-centered treatment. Federal and local guidelines provided are helpful in creating a standard of healthcare organizations to bring change in management. Likewise, practicing patient-centered care (PCC) will require care coordination, improved change in management and smart leadership of healthcare professionals.

    Change in the healthcare setups depends on resources available. The greater the resources available in a healthcare system, the higher and quicker will be the changes achieved. The whole organization should be engaged and enable the change in the healthcare systems that can be possible by huddling meetings where clinicians and support staff members go over the daily medical records and patient list (Carman et al., 2019). 

    Patient experience and patient satisfaction

    Patient experience comprises all the interactions that patients have with healthcare systems and their services and healthcare professionals including the care provided. Changes in management can be made so that patient experience leads to patient satisfaction. Patient satisfaction occurs when all of the patients’ demands are fulfilled, timely appointments, effective and open communication between patients and other healthcare professionals and easy information access. Healthcare professionals should focus on understanding the needs of the patients and make certain changes to fulfill them. (De Rosis et al., 2021).

    Coordinated Care and Ethical Decision Making

    Care coordination cannot be achieved until patients’ priority is kept in mind while planning the care plan for them. There should be implementation of ethical decisions while planning care treatment so that the highest level of coordinated care can be acquired. Care coordinators should make decisions based on the ethical principles of autonomy, beneficence, non-maleficence and justice. These principles are followed when healthcare professionals are confronted with ethical dilemmas and need to make wise decisions for better results. Patient autonomy allows patients to make their own choices regarding desired care intervention. As the sole focus in the healthcare systems is the health of patients, it is important that patients’ priorities be considered in coordinated care (Lulé et al., 2019).

    Patient Centered Care is based on the implementation of ethical principles along with other strategies such as no discrimination, shared decision making, personal relationship, open and effective communication, staff well-being and well behavior with patients, patient’s will to choose a certain treatment that well coordinates with the physician’s. (Hansson & Fröding, 2020). With the shared decision making, adherence to the treatment and medication is improved and it also improves the patient experience of care. In some cases, decisional conflict takes place when the choice of treatment for both health professional and patient does not match.

    Capella 4050 Assessment 3

    In such cases, Decisional Conflict Scale (DCS) is used to measure decisional conflict, which is a 16-item validated, easy-to-use, and credible patient-reported tool. Patients are asked to answer the questions on a 5-point Likert scale (strongly agree to strongly disagree) and this scale differentiates between the patients who are skeptical about their prospective treatment and those who are certain about their treatment. The DCS’s measurement properties tell about the reliability of patients’  knowledge about their disease and treatment which are then assessed and treatment is decided on this basis.

    If the patients are uncertain about the treatment, care coordinators are expected to educate  them about the treatments that their disease demands, for example, by providing resources or showing studies about the cases resolved by following the appropriate treatment plan. Such patient-physician exchanges improves the care coordination and provides clinical insight for patient empowerment, and brings patient satisfaction and less decisional regret. (Roy et al., 2019).

    Impact of Healthcare Policy

    Policies include the rules, regulations and laws that are standardized in any organization to proper functioning. Healthcare policies help in the establishing standards that facilitate organizational working Certain healthcare policies that have an impact on the care coordination are Affordable Care Act (ACA), the Health Insurance Portability and Accountability Act, the Hospital Readmission Reduction Program (HRRP) are examples of such policies. 

    The Affordable Care Act (ACA) is known for covering financial insurance for low-income citizens of America. Affordable Care Act in its initiative Accountable Care Organizations (ACO) supports the care coordination nationwide by using health information technology, transforming the healthcare system to the one that promotes quality over quantity and prevents illness over treating people after they get sick and thus improving the patient experience at the healthcare systems. (Lewis et al., 2019). 

    The Health Insurance Portability and Accountability Act (HIPAA) protects the patient’s sensitive health information from disclosing and hence it helps in caring about the patient’s health privacy and promotes care coordination as care coordination also involves the ethical considerations that regard patient in every possible way and makes the patient experience better with healthcare services. (OCR, 2023).  The Hospital Readmissions Reduction Program (HRRP) grants emergency setups with an irrational number of readmissions to be punished.

    It is done by attaching installment to the certain treatment patient getting and then ensuring efficient care coordination to nullify the occurrence of readmissions. Further, ensuring open communication with patients, their family and the nursing home helps in lessening missteps and loopholes in care along with the continuum of care. This way patients’ experience can be reached to patients’ satisfaction. (Kripalani et al., 2019).

    Nurse’s Role in Coordination and Continuum Care

    Nurses play an important role in care coordination and its continuum as the nurses are the healthcare professionals that are at the forefront of the patients in regards to their care. From assessing patients’ disease conditions to diagnostic test evaluation to administering medication, nurses are pivotal in achieving coordination and continuum of care.  Nurses who are certified in a particular specialty have greater knowledge and serve to bring better results in patient care and bring advancement in professional credibility. Furthermore, specialty certified nurses can deliver motivation by educating and encouraging fellow nurses to acquire certification. Besides, Nurse educators in specialized fields of medicine can also implement specialized competency programs to practice nurses’ knowledge of and adherence to evidence-based practice guidelines (Camicia ey al., 2021). 

    Nurses provide patient-centered integrated care and promote effective and optimal communication and also monitor patient daily reports on progress and symptom relieving and overall patient recovery. They also act as a link between patients and physicians and provide necessary information from patients to physicians and from physicians to patients and coordinate with them effectively. In every healthcare, nurses play a main role in coordination of care and continuum (Young et al., 2020).


    To improve the health of a patient in a true manner requires collaborative work of all healthcare provided in a synchronized way and this is done in a care coordination plan. Care coordination is the need of every healthcare setup. There are different strategies that can be implemented for effective collaboration with the patients and their families to achieve the desired health outcomes. These strategies include communication with patients and their families to gain true and effective knowledge about the patients’ medical history and habits. Others are utilization of telemedicine and building community health networks. Patient-centered care can be implemented to make the patient’s experience better and make ethical decisions for the patient’s treatment. Policies like ACA and HIPAA promote effective outcomes and improve patient experiences. Nurses play a major role in effective coordination and continuum of care.


    Brottman, M. R., Char, D. M., Hattori, R. A., Heeb, R., & Taff, S. D. (2020). Toward cultural competency in Health Care. Academic Medicine, 95(5), 803–813. 

    Camicia, M., Lutz, B., Summers, D., Klassman, L., & Vaughn, S. (2021). Nursing’s role in successful stroke care transitions across the continuum: From acute care into the community. Stroke, 52(12). 

    Carman, A. L., Vanderpool, R. C., Stradtman, L. R., & Edmiston, E. A. (2019). A change-management approach to closing care gaps in a federally qualified Health Center: A rural kentucky case study. Preventing Chronic Disease, 16. 

    De Rosis, S., Barchielli, C., Vainieri, M., & Bellé, N. (2021). The relationship between healthcare service provision models and patient experience. Journal of Health Organization and Management, 36(9), 1–24. 

    Handtke, O., Schilgen, B., & Mösko, M. (2019). Culturally competent healthcare – a scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision. PLOS ONE, 14(7). 

    Hansson, S. O., & Fröding, B. (2020). Ethical conflicts in patient-centred care. Clinical Ethics, 147775092096235. 

    Capella 4050 Assessment 3

    Kripalani, S., Chen, G., Ciampa, P., Theobald, C., Cao, A., McBride, M., Dittus, R. S., & Speroff, T. (2019). A transition care coordinator model reduces hospital readmissions and costs. Contemporary Clinical Trials, 81, 55–61.

    Lewis, V. A., Schoenherr, K., Fraze, T., & Cunningham, A. (2019). Clinical coordination in accountable care organizations: A qualitative study. Health Care Management Review, 44(2), 127–136. 

    Lulé, D., Kübler, A., & Ludolph, A. C. (2019). Ethical principles in patient-centered medical care to support quality of life in amyotrophic lateral sclerosis. Frontiers in Neurology, 10.

    Office for Civil Rights. (2023, February 27). HIPAA Privacy Rule and Care Coordination. Retrieved April 12, 2023, from 

    Oikarainen, A., Mikkonen, K., Kenny, A., Tomietto, M., Tuomikoski, A.-M., Meriläinen, M., Miettunen, J., & Kääriäinen, M. (2019). Educational interventions designed to develop nurses’ Cultural Competence: A Systematic Review. International Journal of Nursing Studies, 98, 75–86. 

    Roy, M., Novak, C. B., Urbach, D. R., McCabe, S. J., von Schroeder, H. P., & Okrainec, K. (2019). Decisional conflict in surgical patients: Should surgeons care? Canadian Journal of Surgery, 62(3), 211–213. 

    World Health Organization. (2021, April 6). Health equity and its determinants. World Health Organization. Retrieved April 11, 2023, from 

    Young, A. M., Charalambous, A., Owen, R. I., Njodzeka, B., Oldenmenger, W. H., Alqudimat, M. R., & So, W. K. (2020). Essential Oncology Nursing Care along the cancer continuum. The Lancet Oncology, 21(12).  

    Capella 4050 Assessment 3