Care Coordination Presentation
Among the healthcare practitioners in the health industry, nurses get tasked with a responsibility to remain proactive and discern the needs of their patients. Different factors, such as state healthcare policies, safety concerns, cultural diversity, and physiological needs of patients, often impact patient outcomes. Besides, such elements get identified as being instrumental in influencing the continuum of care. Continuum of care is an aspect that is advocated for and increasingly being culminated into the patient care delivery models to ensure continued delivery of safe, quality, sustainable, and patient-centered care while reducing care costs. Concerning coordination and continuum of care, nurses have a significant role in mobilizing essential and relevant community resources and personnel. Nurses also are responsible for playing a part in collaborating with patients and family members as a stride to achieve desired healthcare outcomes.
Effective Strategies for collaboration to achieve Desired Health Outcomes
In general, patients with mental health issues require supportive management and monitoring from the relevant family members to meet the client care goals. Concerning my care coordination plan, it imperative that family members of my patients are involved to ensure that collaborative efforts get maximized towards realizing optimum mental health. The personalized, coordinated plan relied on Collaborative Mental Health Care (CMHC) model, which has enough research evidence base. According to Kates, it a model involving primary care and health care providers to collaborate in utilizing community resources and indulge in shared decision-making to make sure patients receive more effective, coordinated, and affordable mental health services (2017). Essentially, the model acknowledges the inclusion of patients and family members as critical partners in care delivery.
One of the strategies for collaborating with the patient and her family is the delivery of patient education. In my coordinated care plan, I commissioned myself to increase the knowledge of my patient and other members of her family on how financial constraints, lack of support from significant others, and setting of unrealistic financial goals cause her mental problems, including depression. The strategy is critical in influencing their attitudes towards supporting and the need to linking her to coping mechanisms and support groups (Menear et al., 2019). Enabling the client to gain access to her electronic health portal and data is another strategy to facilitate communication with the concerned healthcare professionals, through a secure online platform, whenever need be. In the care coordination plan, the patient navigation strategy gets included to increase her and the family members’ awareness of the available support systems and services such as agencies. MHA Affiliate Network and the National Suicide Prevention Lifeline, for example, which have toll-free numbers.
Additionally, family and peer support remain a relevant strategy in partnering with her relatives and peers who had lived such an experience to give their aid while grounding the support on applicable principles of respect and inclusivity. I also put forward employing a shared decision-making strategy, an effort that enables deliberation upon health decisions with the patient and her family members while considering cultural diversity, values, and preferences of the patient. According to Slade (2017), the strategy is essential for mental disorders and that it enables patients and families get aware of available options of management, collaborate with healthcare workers to decide on clinical choices informed by best research evidence based on patient values and preferences.
The healthcare team will also work in handy with the patient and other members of the support system in conducting a needs assessment to identify priority needs and resources required to enhance the health of my client. I would utilize a personalized care plan to highlight and clarify goals and design a consensual arrangement, which is action-based with my patient, her family, and support group members (Coulter et al., 2015). Then, identification of individual strengths and weaknesses will enable the coordination team to identify areas for improvement and work towards meeting the set goals. Sharing of information, knowledge, and resources is also essential as a tool for setting strategies to meet the care coordination objectives.
Change Management Aspects Directly Affecting Elements of the Patient Experience
Regarding the care coordination plan on focus, some of the aspects to foster change management include linking the patient to support groups and peers. Then introduce her to group therapy with a professional counselor, develop a schedule that provides for socialization sessions, and allocate time for engaging in her hobbies. Other aspects include linking the patient to financial planners and counselors, facilitate the development of a financial plan with realistic goals, and encourage her to gain membership in one of the certified Employee Support programs. Such is crucial in effectively managing the impending change for my patient.
To improve patient experience, developing a plan with my patient would smoothly shift into change. Nonetheless, as a nurse, I would facilitate an in-depth understanding of the change among members of the support system. Identification of the aspect will provide meaning to why my client requires intervention for change, including the agreed-upon plan. Engagement is another aspect of successful change management, including contacting the relevant personnel within the community and the purpose of management as per the designed policy.
The rationale for Coordinated Care Plans based on Ethical Decision Making
Focusing on desired patient care outcomes is based on a variety of factors, from which clinicians ought to consider, thus being congruent with ethical decision making. Such factors range from the level of knowledge and skills and insight of the ethical principles relevant to healthcare, including the nursing code of ethics, the establishment of productive relationships with my patient, and support system members, including the family and peers.
Making decisions regarding ethical principles is a necessary consideration in care coordination. Clinicians, led by a nurse, ought to at all costs raise awareness on sharing of patient information to involved other parties; thus, decisions made ought to remain confidential as part of considering ethics. Coordinated care efforts must be anchored to ethical principles, thereby ensuring that members of the community duly follow the guidelines and rules established by clinicians, thus extend their hand within the acceptable limits.
Shared decision making, in this case, will be aligned to deontology, which dictates that ethical decisions are arrived at in circumstances when the involved confer to their roles and responsibilities (Verweij & Dawson, 2018). Another moral principle is utilitarianism that directs that as a care coordination practitioner, I am responsible for the decisions made by considering the ultimate impact of actions of dedicated community support. I will ensure that both act and rule utilitarianism, thus ensuring that the effect of care coordination is widely felt. Subsequently, such ethical considerations are congruent with the purpose of the American Nurses Association’s code of ethics for nurses, which require nurses to consider their profession’s nonnegotiable ethical obligations (Missouri Department of Health and Senior Services, n.d.).
The Potential Impact of Specific Health Care Policy Provisions on Outcomes and Patient Experiences
One of the fundamental health care policy provisions that could impact the healthcare outcomes and experiences of my patient is health insurance. Both private and government insurance firms play a crucial role in catering to the medical expenses of their beneficiaries in coordinated care (Craver, Gimm & Hill, 2018). Considering the different insurance provisions included in the cover, they influence varied experiences in individual patients. Therefore, depending on the services provided to my patient by health insurance, it could positively or negatively impact her health behavior and outcome. Excellent and good patient experiences influence access to quality health care services.
Nurses’ Role in Care Coordination
Nurses have a role in laying strategies to ensure coordination and continuum of care gets effectively conducted. I will engage in performing thorough checks and evaluations, focusing on efforts directed towards collaborated care for my patient. Through the provision of timely and accurate information about the client to the involved individuals, facilitation of continuum of care gets realized. The patient should also be assisted in having insight into the health structures and policies, thus facilitating them to embrace collaborative and working strategies. I also have a role in empowering my patient and her family on relying on informed choices that are essential in the access to quality health care services. Ensuring continuity of coordinated care using affordable community resources is one way of providing affordable care services by reducing healthcare costs to deliver quality care (Kuiper, Pesut & Arms, 2016). As a nurse, I am also obliged to be at the frontline concerning advocating for systems that embrace care coordination and continuum of care.
References
Coulter, A., Entwistle, V. A., Eccles, A., Ryan, S., Shepperd, S., & Perera, R. (2015). Personalized care planning for adults with chronic or long‐term health conditions. Cochrane Database of Systematic Reviews, (3).
Craver, G. A., Gimm, G., & Hill, K. E. V. (2018). Understanding Care Coordination Experiences in a State Medicare-Medicaid Financial Alignment Demonstration. Journal of Health & Human Services Administration, 41(2), 196–236.
Kates, N. (2018). Mental health and primary care: Contributing to mental health system transformation in Canada. Canadian Journal of Community Mental Health, 36(Special Issue), 33-67.
Kuiper, R., Pesut, D. J., & Arms, T. E. (2016). Clinical reasoning and care coordination in advanced practice nursing. Springer Publishing Company.
Menear, M., Dugas, M., Careau, E., Chouinard, M. C., Dogba, M. J., Gagnon, M. P., … & Knowles, S. (2019). Strategies for engaging patients and families in collaborative care programs for depression and anxiety disorders: A systematic review. Journal of affective disorders.
Missouri Department of Health & Senior Services (n.d.). Code of Ethics for Nurses. Retrieved April 9, 2020, from https://health.mo.gov/living/lpha/phnursing/ethics.php
Slade, M. (2017). Implementing shared decision making in routine mental health care. World Psychiatry, 16(2), 146-153.
Verweij, M., & Dawson, A. (2018). Public Health Ethics—10 Years On.