NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project

Name

Capella university

NURS-FPX 6618 Leadership in Care Coordination

Prof. Name

Date

Planning and Presenting a Care Coordination Plan

Hello everyone, my name is __, and I am pleased to present a structured care coordination plan specifically created for individuals managing chronic health conditions. In my role as the Care Coordination Project Manager, I focus on ensuring that patients receive seamless, integrated care tailored to their ongoing health needs. This presentation outlines the fundamental components of a comprehensive strategy designed to improve patient outcomes through coordinated healthcare delivery.

Patients with chronic conditions frequently encounter obstacles in navigating fragmented healthcare systems. Through this presentation, we will explore the strategic elements necessary to close those care gaps. The care coordination plan aims to connect various elements of the healthcare network—including specialists, social services, and community organizations—into one cohesive system. With this approach, patients can experience more efficient, personalized, and sustainable care pathways.

Purpose of the Care Coordination Plan

The intent of a care coordination initiative is to address disjointed care models that often hinder effective chronic condition management. Patients with long-term health needs typically rely on multiple healthcare providers, each of whom may operate in silos. This can result in inefficiencies, duplicated efforts, and inconsistent care. To combat these challenges, the care coordination model promotes communication and collaboration among all parties involved in patient care (Hardman et al., 2020).

This model emphasizes not only clinical integration but also social and emotional support systems, which are essential for managing complex, chronic conditions. By leveraging a person-centered strategy, the plan ensures that the healthcare services align with each patient’s specific goals and preferences. Furthermore, the strategy acknowledges the significance of proactive communication and the use of technological tools that support timely interventions.

Table 1

Summary of Key Aspects of the Care Coordination Plan

Key Aspect	Description	Reference
Purpose of Coordination	Bridges gaps in healthcare by integrating multiple providers and support teams.	Hardman et al., 2020
Vision for Interagency Care	Creates unified care systems that prioritize patient needs through collaboration.	Hunter et al., 2023
Technology Utilization	Employs EHRs, telehealth, and analytics for proactive and connected care.	Northwood et al., 2022

Vision for Interagency Coordinated Care

The envisioned future for interagency care coordination is grounded in seamless service delivery and strong inter-organizational collaboration. Patients with chronic conditions require more than just episodic care—they need comprehensive systems that wrap around their individual health goals and lifestyle needs. The success of such a system lies in establishing effective partnerships among healthcare institutions, social services, and community-based organizations (Hunter et al., 2023).

A primary feature of this vision is the development of a centralized communication hub. This hub will serve as the nexus for information exchange between all stakeholders, including physicians, caregivers, case managers, and patients. Such coordination eliminates redundancies and ensures that care plans are both dynamic and responsive. Integrating digital tools like electronic health records (EHRs), data-sharing platforms, and virtual consultations further supports real-time decision-making and timely interventions (Northwood et al., 2022).

Through shared access to patient information and frequent inter-professional consultations, patients benefit from a more cohesive care experience. For instance, telehealth platforms make routine monitoring accessible, while predictive analytics help identify patients at risk before conditions worsen. The ultimate goal is not only to improve patient outcomes but also to reduce healthcare costs by preventing avoidable complications and hospitalizations.

Assumptions and Uncertainties

A plan of this magnitude requires foundational assumptions about resource availability and system interoperability. One key assumption is that all participating organizations will commit to transparent communication and aligned objectives. Another is that patients will be engaged and proactive in managing their own health, which is a cornerstone of successful care coordination (Kendzerska et al., 2021).

However, significant uncertainties remain. Long-term sustainability of these systems is dependent on continuous funding, stable staffing, and consistent policy support. Shifting healthcare regulations can also create volatility, making it difficult for organizations to maintain continuity in care delivery. Moreover, technological disparities between institutions can hinder data sharing and interoperability, complicating efforts to create unified care records (Kendzerska et al., 2021).

There are also uncertainties around patient participation. Not all individuals are equally equipped or willing to engage in digital health systems or shared decision-making. These factors necessitate an adaptable framework—one capable of evolving as patient demographics, technologies, and care standards change over time.

Identifying the Organizations and Groups

Effective chronic care coordination cannot function in isolation; it requires the cooperation of various stakeholders at different levels of the healthcare system. Local entities play a frontline role in providing direct care and addressing patients’ immediate needs. These include primary care physicians, specialty clinics, hospitals, home health services, and nonprofit community groups (Gizaw et al., 2022).

At the state level, departments of health and Medicaid agencies manage broader structural and financial aspects. These institutions oversee compliance, monitor performance metrics, and help scale successful models. They also offer funding and support through policy tools and professional networks (Centers for Medicare & Medicaid Services, 2021).

Nationally, organizations such as the Centers for Medicare & Medicaid Services (CMS), the American Nurses Association (ANA), and the American Medical Association (AMA) are instrumental in creating clinical standards, promoting best practices, and influencing public policy. Their contributions ensure that care coordination initiatives align with evidence-based practices and regulatory requirements (American Nurses Association, 2023).

Table 2

Key Organizations Involved in Care Coordination

Level	Organizations Involved	Primary Role
Local	Primary care clinics, hospitals, home health agencies, community groups	Deliver direct patient care and social support services.
State	State health departments, Medicaid offices, professional associations	Coordinate resources, enforce healthcare regulations, and manage program funding.
National	CMS, ANA, AMA	Provide national guidelines, promote advocacy, and align policy efforts.

References

American Diabetes Association. (2022). ADA. https://diabetes.org/

American Nurses Association. (2023). American Nurses Association. https://www.nursingworld.org/

Centers for Medicare & Medicaid Services. (2021, March 22). Medicaid home | Medicaid.gov. https://www.medicaid.gov/

NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project

Chakurian, D., & Popejoy, L. (2021). Utilizing the care coordination Atlas as a framework: An integrative review of transitional care models. International Journal of Care Coordination, 24(2), 57–71. https://doi.org/10.1177/20534345211001615

Devi, R., Goodman, C., Dalkin, S., Bate, A., Wright, J., Jones, L., & Spilsbury, K. (2020). Attracting, recruiting and retaining nurses and care workers working in care homes: The need for a nuanced understanding informed by evidence and theory. Age and Ageing, 50(1), 65–67. https://doi.org/10.1093/ageing/afaa109

Farley, H. (2020). Promoting self‐efficacy in patients with chronic disease beyond traditional education: A literature review. Nursing Open, 7(1), 30–41. https://doi.org/10.1002/nop2.382

Gizaw, Z., Astale, T., & Kassie, G. M. (2022). What improves access to primary healthcare services in rural communities? A systematic review. BioMed Central Primary Care, 23(1). https://doi.org/10.1186/s12875-022-01919-0

Hardman, R., Begg, S., & Spelten, E. (2020). What impact do chronic disease self-management support interventions have on health inequity gaps related to socioeconomic status: A systematic review. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-020-5010-4

Hunter, P. V., Ward, H. A., & Puurveen, G. (2023). Trust as a key measure of quality and safety after the restriction of family contact in Canadian long-term care settings during the COVID-19 pandemic. Health Policy, 128, 18–27. https://doi.org/10.1016/j.healthpol.2022.12.009

Kendzerska, T., Zhu, D. T., Gershon, A. S., Edwards, J. D., Peixoto, C., Robillard, R., & Kendall, C. E. (2021). The effects of the health system response to the COVID-19 pandemic on chronic disease management: A narrative review. Risk Management and Healthcare Policy, 14, 575–584. https://doi.org/10.2147/rmhp.s293471

Northwood, M., Shah, A. Q., Abeygunawardena, C., Garnett, A., & Schumacher, C. (2022). Care coordination of older adults with diabetes: A scoping review. Canadian Journal of Diabetes, 47(3), 272–286. https://doi.org/10.1016/j.jcjd.2022.11.004

NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project

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