Introduction

NURS FPX 6203 Assessment 3 Care coordination is critical in delivering patient-focused, high-quality, and affordable healthcare. Nurses have the important responsibility of guaranteeing care follows the patient without interruption across settings and providers. This presentation teaches other nurses the importance of care coordination, evidence-based practice, and interprofessionalism through the use of a case study of a patient with chronic heart failure.

Understanding Care Coordination

Care coordination is the intentional planning of patient care activities and information sharing among all involved participants interested in a patient’s care in order to realize safer and more effective care.

Key Objectives of Care Coordination:

  • Decrease hospital readmissions
  • Enhance patient outcomes
  • Improve care team communication
  • Empower patients and families within the care process
? Learn more from the Agency for Healthcare Research and Quality (AHRQ)

Case Study Overview

Patient: 68-year-old male with congestive heart failure (CHF) Challenges: Frequent readmissions, medication non-adherence, poor dietary control Goal: Create a coordinated care plan to enhance self-management and decrease hospitalizations

Evidence-Based Strategies

1. Transitional Care Model (TCM)

  • Targets patients moving from hospital to home
  • Nurse-coordinated follow-up care
  • Demonstrated to decrease rehospitalization and enhance satisfaction

2. Chronic Care Model (CCM)

  • Focuses on patient self-management
  • Combines clinical information systems and decision support tools
  • Enhances provider-patient relationships

3. Use of Telehealth

  • Remote monitoring of vital signs
  • Virtual visits to monitor medication adherence
  • Decreased demand for emergency visits

Interprofessional Collaboration

Successful care coordination relies on collaboration between:
  • Nurses: Educate, advocate, and monitor
  • Physicians: Modify treatment plans based on data
  • Pharmacists: Coordinate medication regimens
  • Social Workers: Remove psychosocial barriers
  • Dietitians: Help with heart-healthy meal planning

Tools to Enhance Collaboration:

  • Electronic health records (EHR)
  • Interdisciplinary team meetings
  • Shared care plans

Patient and Family Engagement

Engaging patients and families in care planning ensures that:
  • Care is aligned with patient values and preferences
  • Patients comprehend medication, diet, and symptom management
  • Families may assist compliance and recovery

Methods:

  • Teach-back method
  • Motivational interviewing
  • Tailored care plans

How To: Deliver Effective Care Coordination

  1. Evaluate the patient’s needs and goals
  2. Enlist the interprofessional team
  3. Develop a care plan with measurable results
  4. Educate the patient and caregivers
  5. Track and adjust as necessary

FAQs

❓ What is the role of the nurse in care coordination? Nurses screen needs, communicate with providers, educate patients, and track progress toward care objectives.