Care Coordination and Positive Health Outcomes

Introduction

I would like to talk with you about the fundamental principles of care coordination. Care coordination does not have one set definition, as approaches may vary between individuals, organizations, and states. However, generally care coordination implies the organization of patient care in the most effective way, when all of the process participants share information to ensure adequate, safe, effective, and timely care. Information can be shared and care can be coordinated between professionals, divisions, and even different healthcare facilities. This means that additional efforts, time, and resources are necessary to guarantee such synchronization; in most cases, nurses play the most important role within the framework of care coordination. The following topics will be covered in this presentation: effective patient collaboration strategies, change management, ethical decision-making in coordinated care, impacts of healthcare policy provisions on patient experiences, and nurses’ role in care coordination.

Care Coordination

Care coordination has become more significant than it was before, as the healthcare system has been evolving to become more complex and specialized. Moreover, due to the gradual increase in chronic diseases as part of the ongoing epidemiological transition, patients also have to look for more comprehensive treatment options. These factors significantly increase the costs of healthcare services both for patients and healthcare organizations. The situation is exacerbated by the fact that chronic diseases are considered to be the leading cause of death and disability in the United States (Centers for Disease Control, n.d.). Taking that into account, proper care coordination has become critical for healthcare systems, as it is one of the primary tools of chronic disease treatment management.

Effective Patient Collaboration Strategies

One of the main functions within a such collaboration is played by patients and their families and friends. The most effective example of a collaboration strategy with patients and their close ones is the Collaborative Care Model (CCM). CCM is the primary cancer care coordination model, yet it is used with other chronic physical and mental conditions. Kilbourne et al. (2018) mention that CCM “has been shown to improve outcomes for people with chronic physical conditions such as diabetes or congestive heart failure as well as for chronic mental health conditions with little to no net health care costs.” CCM promotes self-management support, proactive care management, and information system-based communication using community resource linkages (Kilbourne et al., 2018). Other strategies that have been noted to be beneficial include patient education, personalized care plans, and self-management support. Self-management is integral as it corresponds to providing adequate care while maintaining the cultural competencies of involved physicians. Similarly, patient education has been noted to increase medication and therapy adherence among patients.

Change Management that Affects the Patient Experience

Given adequate attention and resources, effective care coordination has the potential to improve most of the indicators associated with chronic diseases, such as the costs and length of treatment (Lee & Bae, 2019). Finally, navigating through more complex healthcare systems on their own can be challenging for patients and care coordination can be an appropriate mechanism to solve that problem (Ofei & Paarima, 2021). Overall, changes to care coordination approaches, especially with a focus on ethical decision-making, can positively affect health outcomes and service satisfaction among patients.

Coordinated Care Plans Based on Ethical Decision-Making

Patient care outcomes rely on several factors, and as such, healthcare providers must always assess interventions based on ethical decisions. Essentially, there must be a balanced interaction between the clinical knowledge and skills of a physician, their understanding of ethical principles, and their relationship with the patient and their family. In the case of coordinated care, several primary ethical factors must be considered. These include the sharing of information between involved parties, adherence to standards and regulations, and regard for the patient and maintaining their privacy, integrity, and autonomy. An ethical approach can result in improved quality of care, increased privacy for the patient, and a better understanding of their condition as well as their cooperation in treatment or medication adherence. However, in the case that physicians make certain assumptions throughout care coordination that are unfounded, they may run into issues, contradictions, or disagreements with the patient or even other staff. As such, all underlying assumptions and biases should be reduced or left out of any events in which care coordination is implemented.

Impact of Health Care Policy Provisions on Patient Experiences

The decisions, goals, and actions determined by health policy have a large impact on patient experience. Essentially, it works to establish the guidelines that form all decisions concerning clinical, administrative, ethical, and other challenges or incidents that occur within healthcare settings. Provisions of healthcare policy work to create new requirements for certain groups, often working to expand the reach of healthcare options. Recent issues that often arise are the lack of affordability and emphasis on prevention strategies. Overall, provision aims to reduce ongoing challenges and often reflects more positively on patient experience. However, currently, many changes occur at a pace that is insubstantial and requires further intervention.

Nurses’ Vital Role in the Coordination of Care

Nurses have a leading part in the coordination of care due to the specific set of skills, knowledge, and data that they possess. Nurses have access to the most up-to-date information regarding patients’ health from different sources, which include less formal but equally important sources, such as the patients’ families or patients themselves. Nurses are uniquely equipped for related tasks, largely due to the combined knowledge and skills of negotiation and navigation that are required for care coordination (Izumi et al., 2017). Moreover, many aspects of care coordination are already built into the nurses’ workflow, such as facilitation of the continuity of care, development of care plans, and educating patients and their families. Therefore, nurses play the main role when it comes to the coordination of care, and it is natural for healthcare systems to prioritize nurses and their experience in that sphere. Studies have shown that nurse managers have the appropriate skill to examine the health, and psychological well-being of the patient (Ofer & Paarima, 2021). As a result, this suggests that nursing managers are suitable leaders in conducting care coordination within clinical environments.

Conclusion

Care coordination and related strategies present several advantages that correlate with positive health outcomes and patient experience. Current efforts indicate that the treatment of chronic illness is greatly influenced by modern care coordination and change management prioritizing such practices improves the reception by patients. Similarly, other strategies such as the Collaborative Care Model along with patient education and self-support management have proven to efficiently increase the health outcomes and experiences of a patient. Further policy changes are essential to observe long-term benefits.

References

Center for Disease Control. (n.d.). Chronic Diseases in America. Web.

Izumi, S., Barfield, P.A., Basin, B., Mood, L., Neunzert, C., Tadesse, R., Bradley, K.J., & Tanner, C.A. (2018). Care coordination: Identifying and connecting the most appropriate care to the patients. Research in Nursing and Health, 41(1), 49-56.

Kilbourne, A.M., Hynes, D., O’Toole, T., Atkins, D.A. (2018). Research agenda for care coordination for chronic conditions: aligning implementation, technology, and policy strategies. Translational Behavioral Medicine, 8(3), 515–521.

Lee, J. J., & Bae, S. G. (2019). Implementation of a care coordination system for chronic diseases. Yeungnam University Journal of Medicine, 36(1), 1–7.

Ofei, A.M.A., & Paarima, Y. (2021). Perception of nurse managers’ care coordination practices among nurses at the unit level. International Journal of Care Coordination, 24(1), 17-27.