Nursing: Care Coordination Presentation to Colleagues

Nursing: Care Coordination Presentation to Colleagues



Course, Code: Nursing



Nursing: Care Coordination Presentation to Colleagues

Fundamentals of care coordination in nursing, or as others would call it, principles, represent a critical aspect of the entire nursing practice and, indeed, a core element of the healthcare system. For long, registered nurses’ (RN’s) contributions to the sphere of care coordination have been based on competency and prerequisite regulations standards set by the relevant health bodies, insurers, institutions, and systems. With the evolution of the healthcare system universally, care coordination has continued to continuously receive clinical institutions’ highlights. RNs leverage the spotlight shed on the domain, making it essential to analyze how their contributions, in terms of the policy, ethics, and community resources, enhance service delivery. Various elements in an intertwined system have to come together systematically to ensure the attainment of desired health outcomes.

Introduction and Background

Foremost, it is essential to define care coordination, its fundamentals, and what it entails to the healthcare sphere. According to Luther, Barra, and Martial (2019), care coordination encompasses the deliberate organization of patient care activities, including the sharing of information among all participants involved in the process to attain more effective and safer care. Here, the intent is that the patients’ preferences and needs are well-known well before time and conversed promptly to the appropriate personnel, and that such information is utilized to offer appropriate, safe, and effective patient care. Similarly, as outlined by Belle, et al. (2020), care coordination within the primary care sphere involves the intentional organization of patient care activities to achieve a mutual, well-planned outcome based on patients’ preferences and needs. In contemporary society, RNs apply two distinct approaches of attaining coordinated care: applying broad strategies that are ordinarily utilized to enhance healthcare delivery and utilizing particular care coordination activities. Various examples of comprehensive care techniques include care management, teamwork, medication management, patient-inclined medical home care, and health information technology. On their part, the specific care coordination undertakings include sharing or communicating knowledge, establishing culpability and concurring on responsibility, assisting with transitions that fluctuate in health care, and assessing patient goals and needs. Other activities include monitoring exercises and follow-ups, including making appropriate responses to changes in patients’ preferences and needs, augmenting patients’ management objectives, supporting resources with population and patient needs, and linking to relevant community resources.  

Moving forward, it is critical to define and identify the core fundamentals or principles of care coordination within the healthcare delivery system. As outlined by Pachler et al. (2018), the principal objective of care coordination is meeting patients’ preferences and needs in a changing health care system. Moreover, as augmented by the Institute of Medicine (IoM), care coordination has been identified to have the latency of enhancing the safety, efficiency, and effectiveness of the universal health care framework. Well-planned, targeted, and designed coordination delivered correctly to the relevant persons can enhance the outcomes for every party involved: payers, providers, and most importantly, the patients.

So, why is health care coordination essential among RNs? Despite the need for the aspect to be concise, various significant obstacles have to be surmounted to attain the desired care levels (Friedman et al., 2016). Currently, health care systems are fragmented, implying that the processes vary between and among primary care specialty sites and care sites. Besides, patients are habitually unclear regarding why they are referred from primary care to specialists, book appointments, and what actions to take after visiting specialists. Again, specialists do not dependably receive concise reasons for distinct referrals or sufficient information regarding tests already carried out.

Fundamentals of Care Coordination

The principles of care coordination typically focus on patients and their respective families and the linkages between systems and providers. Additional emphasis is placed on the comprehension of what the patient requires, including the obstacles they encounter (Friedman et al., 2016). The fundamentals of care coordination among RNs include teamwork, collaboration, care continuity, case management, patient or care navigation, chronic care models, and disease management. All the fundamentals are geared towards the objectives of care coordination: assisting patients to be fully engaged in their individual care, helping them to access appropriate, prompt service, and decreasing the disintegration of care. Nevertheless, it is vital to point out that action towards attaining coordinated care is a challenge that individuals and systems have to overcome, especially in various teams working to achieve the same goals.

That said, the most potent fundamentals are continuity, collaboration, and teamwork, which have to be guided by well-laid-out standards and procedures. Continuity is the enabler of care coordination through the creation of conditions and lasting relationships to augment seamless interactions among manifold providers, in care sectors or settings, or among interdisciplinary teams (see figure 1 below) (Chen & Cheng, 2020). Also, teamwork competencies have transformed into a core focus for accreditation by professional, regulatory, and educational organizations, implying that it’s functioning has to follow a standard guide for effective patient outcomes. In contexts of intricate healthcare systems, it is essential to incorporate effective teamwork for patient safety since it diminishes adverse events occasioned by misunderstandings and miscommunications with other practitioners involved in patient care, including miscomprehensions of responsibilities and roles.

Consequently, the issue that emanates is, what can RNs achieve with the fundamentals of care coordination in changing healthcare environments? As outlined by Pachler et al. (2018), transitions and changes are ordinary aspects of health care delivery systems that have to be managed effectively to ensure proper care coordination. The same goes for collaboration: players from different disciplines can come together to brainstorm and attain solutions for patients in primary care or those with chronic conditions (Friedman et al., 2016). Collaborations in care coordination stimulate group thinking and mutual decision-making, which enhance the achievement of set objectives. Besides, crucial leadership is essential for making care coordination function effectively. A transformational leader, in this case, can help to guide teams towards achieving the desired health outcomes through identifying the needs for transformation, establishing a vision intended to guide the changes via inspiration, and implementing the transformations in line with dedicated members of the group.

Figure 1: A patient-inclined care coordinated system encompassing various critical elements

Source: World Health Organization (2018)

That said, it is essential to consider the essential components of ethics, policy, and community resources.

Community Resources

It is essential to link to community resources to achieve successful care coordination among RNs. Community resources, for example, referral facilities, rehabilitation centers, and social working centers provide critical responses to social service needs (Belle et al., 2020). Besides, many stakeholders are involved in the care delivery of patients, including researchers, financiers, and community-based organizations who can offer vital statistics, trends, and demographics regarding patient care. They can then share and communicate essential information that can augment the care coordination process.

 Policy Concerns

In health care coordination, policy concerns are critical because any well-organized activity by RNs has to be sanctioned by the prevailing standards to act as guidelines for practitioners (Friedman et al., 2016). Health care objectives have to be aligned with the relevant policies in their respective jurisdictions. The policies are provided through briefs, papers, or gazette notices that are ordinarily the prerogative of lawmakers. Institutions and practitioners have to ensure that all their actions are as per the standards set by the guidelines to avoid instances of constitutional culpability or prosecution by law. For instance, the American Academy of Nursing policy brief provides guidelines for the patient, population, and family-centered transitional care and care coordination (Lamb et al., 2015). Policy has been identified as an enabling factor in care coordination, especially in the transitional care of trauma victims, primary care, and home care, among other forms of delivery.

Ethical Concerns

In coordination of care, there are various ethical issues that contemporary RN managers face in the process of delivering compassionate and responsible patient care (McBride, 2018). The ethical issues that might arise in care coordination among RNs include patient confidentiality, negligence and malpractice, patient relationships, informed consent, and issues associated with physician-aided suicide (PAD). Nurses are bound by implied and explicit ethical guidelines that are established before and during the course of practice. As such, each RN has to maintain the utmost ethicality of patient wellbeing and fidelity while administering his or her duties in a coordinated care plan. Various regulatory bodies and individual institutions have set their standards for ethics, assessment, and subsequent penalties for infringement, which have to be adhered to.

In conclusion, the fundamentals of care coordination, which are collaboration, continuity, and teamwork, are core to the attainment of positive care coordination. Registered nurses have to ensure the efficacy of care coordination based on ethics, policy, and community resources while simultaneously aligning the activities with perceived changes in the health care delivery system. Care coordination has been identified as key to enhancing patient outcomes, especially with the perpetually transforming health care sphere. However, it is critical to undertake further studies to assess novel ways of making care coordination work better presently and in the future.


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Chen, C.-C., & Cheng, S.-H. (2020). Care continuity and care coordination: A preliminary examination of their effects on hospitalization. Medical Care Research and Review,

Friedman, A., Howard, J., Shaw, E. K., Cohen, D. J., Shahidi, L., & Ferrante, J. M. (2016). Risk-based forecasting facilitators and barriers to care coordination in patient-centered medical homes (PCMHs) from coordinators’ Perspectives planning and management earnings forecasts. Journal of American Board of Family Medicine, 29(1), 90-101.

Lamb, G., Newhouse, R., Beverly, C., Beverly, C., Beverly, C., Beverly, C., . . . Beverly, C. (2015). Policy agenda for nurse-led care coordination. Nursing Outlook, 521-530.

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McBride, S. (2018). Identifying and addressing ethical issues with the use of electronic health records. The Online Journal of Issues in Nursing, 23(1),

Pachler, D., Kuonath, A., Specht, J., Kennecke, S., Agthe, M., & Frey, D. (2018). Workflow interruptions and employee work outcomes: The moderating role of polychronicity. Journal of Occupational Health Psychology, 23, 417–427. 10.1037/ocp0000094.

World Health Organization. (2018). Continuity and coordination of care. World Health Organization, 1-76.,in%20care%20settings%20or%20sectors.&text=care%20and%20Coordinating%20services%20within,around%20the%20needs%2.

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