NURS FPX 4065 Assessment 4 Care Coordination Presentation to Colleagues
Student Name
Capella University
NURS-FPX4065 Patient-Centered Care Coordination
Prof. Name
Date
Care Coordination Presentation to Colleagues
Care Coordination (CC) is responsible for improved patient outcomes and seamless healthcare delivery. Nurses link patients, families, and care teams for ongoing support (Karam et al., 2021). This assessment addresses evidence-based approaches to patient and family collaboration. It also emphasizes enhancing patient experiences and ethical care choices. Nurses are at the center of patient-focused care. CC ensures equitable and effective treatment.
Evidence-Based Strategies
Effective CC depends on providing care that is both evidence-based and culturally sensitive. One key approach is Shared Decision-Making (SDM), where patients and medical professionals collaborate to make informed treatment decisions. According to Resnicow et al. (2021), SDM should be flexible and adapted to personalized health concerns of patients and preferences, as some can require more guidance from providers based on their situation. Nurses play a vital role in supporting SDM by using tools like decision aids, teach-back methods, and plain language communication to help patients understand their options and feel confident in managing their care.
These strategies enhance patient autonomy and engagement, which are essential goals of coordinated care. Cultural competence is another crucial element in CC. Nurses need to understand how cultural beliefs, language barriers, and traditional practices influence patients’ health behaviors and expectations. The U.S. Department of Health and Human Services (HHS) supports national standards to ensure care models address the needs of Culturally and Linguistically Diverse (CALD) populations. These standards promote equity and guide providers in delivering inclusive care that respects each patient’s background. For example, providing health education materials in a patient’s preferred language and including family in decision-making processes help strengthen trust and improve communication.
NURS FPX 4065 Assessment 4 Care Coordination Presentation to Colleagues
When nurses apply culturally appropriate interventions, they help reduce health disparities and build stronger relationships with the communities they serve. Finally, family involvement is essential to achieving long-term success for patients with chronic illnesses like diabetes and asthma. Nurses educate families about treatment plans, self-care, and available community resources. When families are empowered with culturally relevant education materials tailored to literacy levels, they can better support patients at home and help prevent complications. Nurses collaborate with community health workers to reinforce this education and improve health outcomes (Karam et al., 2021). Together, these evidence-based, culturally sensitive, and family-centered strategies create a solid foundation for effective, patient-focused CC.
Change Management
In CC, change management is not merely about changing systems and policies; it is about preparing frontline workers, nurses, to lead and maintain improvements that have a direct impact on patients. One of the biggest challenges in CC is ensuring clear and consistent communication throughout all transitions. In implementing innovations like team care models and revised discharge procedures, nurses must be engaged early to make the changes feasible and patient-focused. Lewin’s Change Management Model includes three phases: unfreezing, changing, and refreezing (Barrow, 2022). In the process of unfreezing, nurses identify the necessity for the change and prepare the team. In the changing process, new care processes are implemented and experimented with.
During the refreezing stage, recent updates are made permanent and become the standard. This allows nurses to confidently lead improvement and ensure patients receive safe, consistent care.Improving patient experience requires change management that ensures continuity during handoffs between providers, departments, and care settings. Fragmented transitions can lead to missed instructions, repeated tests, and medication errors. To prevent this, nurse leaders use standardized tools like SBAR (Situation, Background, Assessment, Recommendation) and start discharge education early. Unlike traditional models focused only on satisfaction surveys, coordinated care now emphasizes patients’ real experiences, such as pain management, clear discharge instructions, and being heard.
These aspects depend on how well organizations manage change at the point of care. Effective CC means nurses handle small but meaningful changes that directly affect patients, like simplifying appointment scheduling, reducing response delays, and offering real-time follow-up calls. When patients understand instructions, dissatisfaction increases if delays and confusion occur. This shows that better coordination and staff training on these small changes can build more patient trust than large reforms. Change management is thus a tool to develop patient-centered care from the ground up (Barrow, 2022).
Rationale for Coordinated Care
In nursing practice, organized care should be based on ethical values to provide justice, safety, and dignity for all patients. The American Nurses Association Code of Ethics directs nurses to safeguard patients’ rights while ensuring safe, empathetic, and person-centered care (ANA, 2025). Autonomy, beneficence, and justice-based care plans involve patients in making decisions about their health. This includes involving families in chronic disease management, respecting patient preferences, and supporting informed choices..Ethical care also means addressing barriers like limited transportation and language differences. This can be done using interpreter services, clear discharge instructions, and community referrals to minimize mistakes and enhance patient care compliance.
Early implementation of SDM reinforces care transitions and reduces conflicts, with care being coordinated and patient-value aligned. This model is based on assumptions that patients are worthy of respect and autonomy, that cultural competency enhances care, and that care should be person-centered. These values guide nursing practices, from discussing medication risk to advocating for follow-up, and result in improved patient engagement, satisfaction, and outcomes. Nurses also gain greater confidence as they understand that their actions are guided by professional ethical standards and minimize moral distress (Ilori et al., 2024). Ethical decision-making helps to promote trust, improve communication, and uphold the integrity of nursing practice in all healthcare facilities.
Impact of Health Care Policy Provisions
Health care policies strongly influence how nurses coordinate care and improve patient outcomes. The Affordable Care Act (ACA) has expanded access to care by increasing Medicaid coverage and requiring insurance to include preventive services (Ercia, 2021). This allows more patients to receive early treatment, manage chronic conditions, and stay out of the hospital. The ACA also supports Accountable Care Organizations (ACOs), which encourage providers to work together. In these models, nurses are essential in planning care, educating patients, and following up after discharge. These actions reduce gaps in care, improve communication, and help patients stay on track with their treatment.
The Health Insurance Portability and Accountability Act (HIPAA) safeguards patient data and guides how nurses share data. When nurses follow HIPAA rules, patients feel safe and respected, which builds trust essential for CC and patient engagement. Clear privacy rules enable nurses to update the healthcare team while respecting patient rights. Poor privacy handling can make patients uncomfortable and reluctant to seek care. HIPAA fosters an environment where patients feel involved and supported. Another key policy change is the growth of telehealth after COVID-19. New policies have made virtual care easier for nurses to provide, helping patients in rural and underserved areas receive regular check-ins, medication support, and chronic disease management without travel. As Moulaei et al. (2023) note, telehealth improves satisfaction by increasing access and flexibility. Nurses use telehealth to monitor symptoms, answer questions, and guide patients between visits. These efforts strengthen CC and maintain strong connections throughout the care continuum.
Nurse’s Role in Coordination
Nurses serve as key coordinators in the healthcare system, helping patients move safely and smoothly across different care settings. Whether transitioning from hospital to home and managing long-term conditions in the community, nurses ensure that care is continuous, well-organized, and responsive to each patient’s needs. They support patients and families by explaining medications, teaching self-care skills, and providing lifestyle education to prevent complications. Nurses also assess ongoing needs and communicate with interdisciplinary team members to revise care plans as a patient’s condition changes (Karam et al., 2021). This coordination helps reduce hospital readmissions, improve outcomes, and build trust in the care process.
Health care policies have recognized and expanded the nurse’s role in leading coordinated care efforts. For example, value-based care models reward healthcare teams for improving the quality of care rather than the number of procedures. These models position nurses as central figures in managing discharge planning, follow-up calls, and community referrals that support long-term health. Programs like the Centers for Medicare & Medicaid Services (CMS) Chronic Care Management (CCM) initiative highlight the importance of nurse-led care for patients with multiple ongoing health issues. These policies help healthcare organizations reduce costs and improve quality by investing in nurse-driven coordination strategies. When nurses are empowered to guide patients across the continuum, care becomes safer, more efficient, and truly centered on the individual.
Conclusion
Effective CC improves patient safety and satisfaction. Nurses lead in managing transitions across care settings. Using evidence-based methods strengthens care quality. Policies like the ACA support nurse-led coordination. Ethical care respects patient values and needs. Collaboration reduces errors and improves outcomes. CC is vital for a better 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. BioMed Central 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. BioMed Central Medical Informatics and Decision Making, 23(1). https://doi.org/10.1186/s12911-023-02348-4
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
