Student Name
Capella University
NURS-FPX4065 Patient-Centered Care Coordination
Prof. Name
Date
Care Coordination Presentation to Colleagues
Care Coordination (CC) is a patient-centered process designed to improve health outcomes and ensure smooth healthcare delivery. Nurses play a crucial role as the connecting link between patients, families, and interdisciplinary care teams, ensuring that every patient receives continuous support (Karam et al., 2021). This presentation emphasizes evidence-based strategies for collaboration with patients and families, ethical approaches to decision-making, and the role of healthcare policies in enhancing CC. Ultimately, the nurse’s leadership in this area ensures fair, effective, and high-quality care.
Evidence-Based Strategies
Effective CC relies on strategies that are grounded in research and adapted to meet cultural and individual needs. A central approach is Shared Decision-Making (SDM), in which patients and providers work together to make informed healthcare choices. Resnicow et al. (2021) highlight that SDM should be flexible and individualized, recognizing that some patients require more guidance from providers due to complex conditions or limited health literacy.
Nurses facilitate SDM through the use of decision aids, teach-back methods, and clear communication tools. These not only empower patients to understand their treatment plans but also strengthen autonomy and engagement, which are fundamental goals of CC.
Another vital aspect is cultural competence. Nurses must understand how cultural practices, values, and language barriers affect patients’ healthcare behaviors. The U.S. Department of Health and Human Services (HHS) has developed national standards to ensure care meets the needs of Culturally and Linguistically Diverse (CALD) populations. For example, tailoring patient education materials to language preferences and literacy levels while involving families in care decisions improves trust and engagement.
Finally, family involvement plays a pivotal role, especially for chronic conditions like asthma, heart disease, and diabetes. Nurses educate families on treatment adherence, home management, and available community resources. By working closely with community health workers, they reinforce care strategies and reduce risks of complications (Karam et al., 2021). These evidence-based, culturally sensitive, and family-centered methods establish a foundation for effective CC.
Table 1
Key Evidence-Based Strategies for Care Coordination
| Strategy | Description | Nursing Role |
|---|---|---|
| Shared Decision-Making (SDM) | Collaboration between patients and providers for treatment choices | Use decision aids, plain language, and teach-back to guide patients |
| Cultural Competence | Adapting care to cultural, linguistic, and social needs | Provide materials in patient’s language, respect traditions, and include family involvement |
| Family Engagement | Empowering families in chronic disease management | Educate families, connect to community health workers, and provide culturally relevant support |
Change Management
In healthcare, change management is essential for nurses to successfully lead and sustain improvements that affect patient outcomes. One of the biggest challenges in CC is ensuring consistent communication across care transitions. Fragmented communication often leads to duplication of tests, delayed treatments, and medication errors.
Lewin’s Change Management Model (Barrow, 2022) is a useful framework in CC:
Table 2
Lewin’s Change Management Model in Care Coordination
| Stage | Description | Nursing Application |
|---|---|---|
| Unfreezing | Recognizing the need for change and preparing teams | Nurses identify gaps in patient handoffs and educate peers on communication needs |
| Changing | Implementing new strategies and processes | Trial of SBAR, early discharge education, and team-based approaches |
| Refreezing | Making changes permanent and integrating them into standard practice | Embedding new processes in policy and training to ensure consistent patient outcomes |
Effective CC requires small yet meaningful adjustments such as streamlined appointment scheduling, improved discharge teaching, and proactive follow-up calls. These improvements may appear minor, but they significantly influence patient experiences by reducing delays, preventing confusion, and strengthening trust.
Rationale for Coordinated Care
Coordinated care must align with ethical principles that safeguard patient dignity, justice, and safety. The American Nurses Association (ANA) Code of Ethics directs nurses to advocate for patients’ rights and involve them in health decisions (ANA, 2025). Ethical CC is built on autonomy, beneficence, and justice, ensuring patients’ voices are respected in treatment decisions.
For example, addressing barriers such as language differences through interpreter services or transportation challenges with community referrals allows for equitable care delivery. Nurses reduce health inequities by reinforcing Shared Decision-Making and advocating for interventions that are aligned with patients’ values (Ilori et al., 2024).
Ultimately, this ethical foundation empowers both patients and nurses. Patients experience greater satisfaction and compliance, while nurses gain confidence and reduce moral distress by adhering to professional ethical guidelines.
Impact of Health Care Policy Provisions
Healthcare policies significantly influence CC by shaping how nurses deliver care. The Affordable Care Act (ACA) increased insurance coverage and expanded preventive services, allowing earlier treatment and better chronic disease management (Ercia, 2021). Nurses contribute to ACA’s Accountable Care Organizations (ACOs) by educating patients, coordinating follow-ups, and bridging care gaps.
The Health Insurance Portability and Accountability Act (HIPAA) protects patient privacy. By complying with HIPAA, nurses build trust with patients while safely sharing data among providers. Conversely, privacy breaches can discourage patients from seeking care, undermining CC.
The expansion of telehealth policies post-COVID-19 has been particularly impactful. Telemedicine provides accessible, affordable follow-ups, especially for underserved or rural populations. Nurses use telehealth to monitor symptoms, educate patients, and provide timely guidance, which strengthens CC (Moulaei et al., 2023).
Nurse’s Role in Coordination
Nurses are the backbone of CC, ensuring that patients transition safely across settings while receiving comprehensive and personalized support. Their responsibilities include medication education, self-care training, discharge planning, and long-term follow-up (Karam et al., 2021).
Additionally, nurses work with interdisciplinary teams to revise care plans and ensure continuity as patient conditions change. Policies like value-based care models and CMS Chronic Care Management (CCM) programs highlight the critical role of nurses in reducing readmissions and improving quality while lowering costs.
Through empowerment, nurses build stronger patient relationships and act as advocates, educators, and coordinators across the healthcare continuum.
Conclusion
Care Coordination (CC) strengthens patient outcomes by reducing errors, enhancing satisfaction, and promoting continuity of care. Nurses are leaders in this process, applying evidence-based strategies, leading change, and ensuring ethical and policy-aligned practices. With the support of healthcare policies and family engagement, CC builds a safer and more equitable 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
NURS FPX 4065 Assessment 4 Care Coordination Presentation to Colleagues
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
Moulaei, K., Sheikhtaheri, A., Fatehi, F., Yazdani, A., & Bahaadinbeigy, K. (2023). Patients’ perspectives and preferences toward telemedicine versus in-person visits: A mixed-methods study on 1226 patients. BMC Medical Informatics and Decision Making, 23(1). https://doi.org/10.1186/s12911-023-02348-4
NURS FPX 4065 Assessment 4 Care Coordination Presentation to Colleagues
Resnicow, K., Catley, D., Goggin, K., Hawley, S., & Williams, G. C. (2021). Shared decision making in health care: Theoretical perspectives for why it works and for whom. Medical Decision Making, 42(6), 755–764. https://doi.org/10.1177/0272989×211058068