Care coordination is the foundation of most healthcare redesign efforts, such as behavioral and primary healthcare integration.
It entails bringing together different information systems and providers to coordinate health services, information and patient needs to help better attain the care and treatment goals ( Goodridge, Isinger & Rotter, 2018) .
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Care coordination enhances clinical outcomes, efficiency and patient satisfaction with care.
Care coordination is an essential, ongoing element of an effective care system for patients.
It engages families in the creation of a care plan and connects them to health and other services which address the full range of their concerns and needs.
Care coordination principles reflect the core role of families and the prioritization of patient and family needs, needs and strengths in effective care of patients. Care coordination activities might differ from one family to another ( Goodridge, Isinger & Rotter, 2018) .
Principles of Care Coordination
Accessibility: it should be continuous across service systems and across transitions as important to family.
Individualization: it should be based on family strengths, needs and circumstances.
Aligned with the family in its interactions with wider community ( Gibbings & Wickramasinghe, 2018) .
Promote solution of systematic problems through of care coordination guided by clear ethics and standards.
Person-centered: It should ensure the individual’s decisions concerning service type and delivery are respected.
Assessment driven: It must be founded on an assessment, including, as suitable, the patient’s psychosocial, mental, physical, and cognitive functioning, medication use, spirituality, use of adaptive equipment, as well as family caregiver ability to offer care ( Gibbings & Wickramasinghe, 2018) .
Comprehensive written care plan: The assessment process outcome must be a comprehensive written care plan, created collaboratively with the patient, and risk assessment which addresses all of the patient’s mental, psychological, cognitive, physical and family support needs ( Gibbings & Wickramasinghe, 2018) .
Care coordinator qualifications: A care coordinator must be aware of and understand the patient’s goals, culture, abilities, and psychological and medical needs and have the ability to manage the needs.
Effective Strategies for Collaborating with Patients and their Families
Leadership and accountability
The healthcare and patients should agree on goals and clearly define roles and accountability for goal attainment.
Clinical team members provide advice on clinical elements.
Families and patients offer their perspectives until there is consensus on goals ( Menear et al., 2020).
Teamwork and communication
Families and patients are regarded as part of the team and should get timely, accurate and relevant about their care and health ( Goodridge et al., 2018) .
Psychological safety
Patients must feel psychologically secure to share their concerns and needs with the clinical team ( Menear et al., 2020) .
Healthcare team members should get patient viewpoints openly and without judgment.
Patients should be transparent about their health symptoms, signs, and treatment adherence.
Negotiation
The healthcare team should engage in collaborative negotiation with families and patients.
Healthcare team must know the patient’s worries, concerns, and desired outcomes ( Menear et al., 2020).
Transparency
Patients with families and patients, especially regarding adverse events, should be promoted.
There should be opportunities for families and patients to engage in care, and use opportunities like patient portals ( Goodridge et al., 2018) .
Reliability
Patients should help in developing ways to make the coordination procedure more reliable.
Improvement and measurement
Patients must share experiences, perspectives, and ideas regarding ongoing improvement efforts.
Patient Education
The healthcare team should provide strategies to increase patient knowledge on how to improve heal or prevent diseases ( Menear et al., 2020) .
Access to health portals or records
Patients and families should be able to access their paper or electronic medical records.
Patients must be to access personal health information.
Patients must be able to communicate with their providers via a secure online platform ( Goodridge et al., 2018) .
Behavior change interventions
There should be interventions focused on creating direct behavior change in patients and families.
Personalized care planning
The patient care should be personalized to meet the patients’ needs.
Self-management supports
The healthcare team should inform patients and families on the ways they can perform self-care management of their symptoms and treatment plan ( Goodridge et al., 2018) .
Shared decision-making
Healthcare providers, patients and families should make health decisions through deliberations, considering best available evidence, professional clinical judgment, and the preferences and values of patients and families ( Goodridge et al., 2018) .
Peer supports
People with healthcare experience should offer patients and families the necessary support ( Goodridge et al., 2018) .
The Change Management Aspects that Directly Affect the Patient Experience Elements
Clear Communication
There should be a clear definition of the reason for the change.
The health management team must communicate with the staff what will be asked of them and explain the benefits of change, in regard to improving patient experience.
Being Empathetic, Not Sympathetic
The health management team should genuinely care about the staff.
Leaders can support the by lending an empathetic ear and keep them aligned with the change objective.
Work with the Willing
The leaders implementing the change should work with the staff prepared to do their part to facilitate change management towards improving patient experience.
Hold Employees Accountable
Accountability is a crucial value to uphold while managing change.
Leaders should set expectations and promote personal accountability to create a culture of accountability.
Change needs new habits to align with organizational goals.
Integration and Coordination of care
Coordinate clinical care
Coordinate support and subsidiary services
Coordinate front-line patient care
Respect patient’s expressed needs, preferences and values
The change management process must involve patients in decision-making.
Patients should be treated with respect, dignity, and sensitivity to their cultural autonomy and values.
Education and Information
Patients should be informed about the change, clinical status and progress.
Information the new care processes
Information to promote health promotion, self-care and autonomy.
The Rationale for Coordinated Care Plans Based On Ethical Decision Making
Nurses must understand that healthcare is governed by a set of ethical principles.
The decision-making process should patient-oriented as much as possible and the coordinated care plan should integrate the ethical responsibilities of the nurses ( Leppänen, 2016 .
Patients have the right to make decisions about their healthcare and choose to refuse or accept treatment.
Nurses should provide complete and accurate information about the patients’ conditions, to allow patients make informed decisions ( Leppänen, 2016) .
The coordinate care plans should consider any ethical issues which might arise when caring for the patients.
Nurses must remember that every patient has a right to be treated equally and fairly, while nurses have a duty to abstain from maltreatment, reduce harm, and promote good health toward patients.
Nurses should help patients with tasks which they cannot perform on their own.
Nurses should be aware that failing to follow the ethical principles of nursing could result in suspension from work, lawsuits, dismissal, and forfeiture of certificates by nurses ( Leppänen, 2016) .
Nurses must obtain informed consent before any procedure or treatment, unless patient is unconscious.
Nurses should maintain patient confidentiality and tell the truth.
Nurses should deal with the beliefs which conflict with experiential knowledge in the coordinated care plans ( Leppänen, 2016) .
The Potential Impact of Specific Health Care Policy Provisions on Outcomes and Patient Experiences.
A health policy denotes the plans, decisions, and actions undertaken to attain specific healthcare goals.
An explicit healthcare policy could have various implications:
A healthcare policy defines a vision for the future.
It establishes targets and reference points for the short and medium term.
It outlines priorities and the anticipated roles of nurses and providers.
A specific example of healthcare policy is public health policy.
A public health policy can create, regulate and uphold public health services for fostering supportive environment for promoting patient outcomes and experiences.
A public health policy can regulate public health resources to enhance care provision.
A public health policy can create requirements that boost patient outcomes and experiences.
A public health policy can reduce barriers to healthcare access, thus enhancing patient outcomes and experiences.
References
Goodridge, D., Henry, C., Watson, E., McDonald, M., New, L., Harrison, E. L., ... & Rotter, T. (2018). Structured approaches to promote patient and family engagement in treatment in acute care hospital settings: protocol for a systematic scoping review. Systematic reviews , 7 (1), 35.
Goodridge, D., Isinger, T., & Rotter, T. (2018). Patient family advisors’ perspectives on engagement in health ‐ care quality improvement initiatives: Power and partnership. Health Expectations , 21 (1), 379-386.
Gibbings, R., & Wickramasinghe, N. (2018). Care Coordination Conceptual Framework.
Menear, M., Dugas, M., Careau, E., Chouinard, M. C., Dogba, M. J., Gagnon, M. P., ... & Knowles, S. (2020). Strategies for engaging patients and families in collaborative care programs for depression and anxiety disorders: A systematic review. Journal of affective disorders , 263 , 528-539.
Leppänen, J. (2016). Nurses experiences of ethical decision making in nursing.
