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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 Date Purpose of Planning and Presenting a Care Coordination Project This assessment is projected toward developing a care coordination project plan for chronic care patients in the Virginia community. Elderly people in the Virginia community suffer from chronic diseases, resulting in higher comorbidities and mortalities. The quality of care provided to chronic disease patients lacks adequate care coordination, leading to poor health outcomes in elderly patients. The hospital readmission rates are devastatingly increasing daily due to poor management of chronic conditions like diabetes, hypertension, renal diseases, chronic obstructive pulmonary disease, etc. Moreover, medication error rates are burgeoning in chronic care patients due to a lack of coordination among healthcare professionals. As a care coordinator project manager at Sentara Northern Virginia Medical Centers, 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 inflicted 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 coordination care for chronic care patients is patient-centered and collaborative care, prioritizing the overall well-being of elderly population with chronic conditions. This is possible by integrating a multidisciplinary team collaboration of healthcare professionals, including physicians, nurses, pharmacists, social workers, dieticians, etc. The care coordinating teams will enable effective care delivery through adequate coordination and collaboration, leaving no room for errors or treatment delays. Therefore, effective sharing of patient health data among healthcare professionals is neccessary. This can be done by using healthcare technologies such as electronic health records that enhances smooth coordination and communication, as the EHR can be integrated into multiple organizations (Southerland et al., 2020). A patient-centered care approach can be delivered in several ways, from onsite followups to online consultations by telehealth technology. By leveraging technology, healthcare providers can give consolidated care remotely, and patients can acquire 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 a 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, the 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 Ageing,” 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 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 Ageing is a widespread network of agencies in Virginia that works for chronic diseases among elderly people and promotes 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, 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, dieticians, 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 patients with community resources. The dieticians will provide nutrition counseling for patients requiring lifestyle modifications. The case manager will oversee care transitions, ensure seamless communication, and manage 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.