NURS FPX 4065 Assessment 4 Care Coordination Presentation to Colleagues

Name

Capella university

NURS-FPX4065 Patient-Centered Care Coordination

Prof. Name

Date

Care Coordination Presentation to Colleagues

Care Coordination (CC) plays a critical role in ensuring that patients receive seamless, safe, and effective healthcare services. It involves connecting patients, their families, and healthcare teams to achieve optimal outcomes. Nurses serve as the link between these groups by facilitating communication, promoting patient engagement, and ensuring ethical and patient-centered practices (Karam et al., 2021). This presentation highlights evidence-based strategies, change management processes, ethical considerations, and the impact of healthcare policies on care coordination. Ultimately, CC aims to create an environment where patients receive equitable and efficient care that reflects their needs and values.

Evidence-Based Strategies

Evidence-based practices are essential for strengthening patient and family involvement in healthcare. Shared Decision-Making (SDM) is one such strategy, allowing patients and providers to collaborate on treatment decisions. According to Resnicow et al. (2021), SDM adapts to each patient’s needs, recognizing that some may require more guidance from clinicians than others. Nurses enhance this process through communication techniques such as decision aids, simplified explanations, and the teach-back method, ensuring patients fully understand their care options.

Another key element is cultural competence. Nurses must acknowledge the role of cultural traditions, language, and beliefs in shaping patient behaviors. National standards, such as those from the U.S. Department of Health and Human Services (HHS), promote culturally and linguistically inclusive practices. Examples include offering educational materials in a patient’s preferred language and involving families in treatment planning. These strategies help reduce health inequities and build stronger relationships with diverse communities.

Family engagement also strengthens care outcomes, especially for patients with chronic illnesses like asthma, diabetes, or hypertension. Nurses educate families on treatment plans, connect them with community resources, and collaborate with community health workers to reinforce health education (Karam et al., 2021). These combined approaches—evidence-based, culturally sensitive, and family-focused—create a robust foundation for CC.

Table 1

Evidence-Based Strategies for Effective Care Coordination

Strategy	Description	Nurse’s Role
Shared Decision-Making (SDM)	Patients and providers jointly make healthcare decisions.	Use decision aids, teach-back method, plain language for clarity.
Cultural Competence	Care that respects language, cultural, and religious practices.	Provide translated materials, include families, reduce disparities.
Family Engagement	Educating and empowering families in chronic illness management.	Offer culturally tailored education, connect to resources, collaborate with community health workers.

Change Management

Change management in CC goes beyond adjusting systems and policies; it focuses on preparing nurses and care teams to sustain improvements. Effective communication during transitions is one of the most challenging aspects. For example, new discharge protocols and team-based care models require nurse involvement early in the process to ensure changes are practical and centered on patients (Barrow, 2022).

Lewin’s Change Management Model outlines three stages:

Unfreezing – Nurses recognize the need for change and prepare the team.
Changing – New processes are tested and applied.
Refreezing – Updates become standard practice to ensure consistency.

During patient transitions, fragmented communication can result in repeated tests, errors, or medication mismanagement. Nurses address these issues by applying standardized tools like SBAR (Situation, Background, Assessment, Recommendation) and by beginning discharge planning early. Unlike traditional satisfaction-focused models, modern CC emphasizes patient experiences such as pain management, clear communication, and timely follow-up.

Small-scale improvements, such as streamlining appointment scheduling or reducing wait times for follow-up calls, significantly impact patient trust. These seemingly minor changes ensure smoother transitions and strengthen patient engagement. Change management thus empowers nurses to build patient-centered systems from the ground up (Barrow, 2022).

Table 2

Change Management in Care Coordination

Phase (Lewin’s Model)	Activities in Nursing Practice	Outcomes
Unfreezing	Identify gaps, raise awareness, prepare staff.	Team readiness for change.
Changing	Implement new discharge protocols, test SBAR handoffs.	Improved care transitions and reduced communication gaps.
Refreezing	Make new practices permanent.	Safe, consistent, and standardized patient care.

Rationale for Coordinated Care

Coordinated care in nursing is guided by ethical values that promote dignity, fairness, and respect for all patients. The American Nurses Association (ANA) Code of Ethics emphasizes protecting patient rights while delivering compassionate, safe, and patient-centered care (ANA, 2025). Principles such as autonomy, beneficence, and justice serve as a foundation for ethical care.

Ethical practice includes involving families in chronic disease management, respecting patient preferences, and providing access to interpreter services for non-English speakers. These measures ensure that barriers like language or transportation challenges do not compromise care. Furthermore, early implementation of SDM minimizes conflicts during transitions and supports patient-aligned decisions (Ilori et al., 2024).

Nurses benefit from ethical practice as well, since working under clear ethical standards reduces moral distress and enhances professional confidence. Ultimately, coordinated care ensures patients feel respected and valued, improving trust, satisfaction, and adherence to treatment plans.

Impact of Health Care Policy Provisions

Healthcare policies shape how nurses coordinate care and improve outcomes. The Affordable Care Act (ACA) expanded Medicaid coverage, requiring insurance plans to include preventive services. This has increased patient access to early interventions and reduced hospitalizations (Ercia, 2021). ACA-supported Accountable Care Organizations (ACOs) encourage collaborative care models, where nurses play a central role in patient education and post-discharge follow-ups.

The Health Insurance Portability and Accountability Act (HIPAA) also plays a vital role in CC by protecting patient privacy. When nurses safeguard health information, they foster trust, allowing patients to engage more openly in their care. Mishandling privacy, however, creates reluctance and fear among patients.

Additionally, the COVID-19 pandemic accelerated the adoption of telehealth, supported by new policy frameworks. Telehealth allows nurses to conduct virtual visits, monitor chronic conditions, and offer medication support to rural and underserved populations (Moulaei et al., 2023). These policies collectively improve equity, patient trust, and the overall effectiveness of CC.

Nurse’s Role in Coordination

Nurses are the cornerstone of CC, ensuring smooth transitions across healthcare settings. They educate patients and families on medications, lifestyle changes, and follow-up care while collaborating with interdisciplinary teams to adapt plans based on evolving needs (Karam et al., 2021).

Policy changes such as value-based care models recognize nurses’ contributions by rewarding improvements in care quality rather than the number of procedures. Programs like CMS’s Chronic Care Management (CCM) initiative highlight the importance of nurse-led coordination, particularly for patients with multiple chronic conditions.

By guiding patients across the care continuum, nurses reduce readmissions, enhance patient safety, and promote satisfaction. Empowering nurses in these roles leads to safer, cost-effective, and patient-centered care systems.

Conclusion

Care Coordination is central to improving patient outcomes, ensuring safety, and enhancing the overall healthcare experience. Nurses play a vital role in leading transitions, implementing evidence-based strategies, and applying ethical principles. With the support of policies like the ACA and HIPAA, as well as innovations like telehealth, CC becomes more accessible and effective. Collaboration, cultural sensitivity, and patient-family engagement remain at the heart of CC, making it a critical tool in building a more equitable and efficient healthcare system.

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. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459380/

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