Essay Care Coordination in the Health Care System

The healthcare industry has intensely advanced throughout the world, in turn changing the principles that incorporate the practice and culture of nursing practice. Altering the model of care to a patient-centered mode signifies an organizational culture shift and requires the participation of executives at the senior level (Cliff, 2012). To practice this care to provide the best care possible, it goes beyond the nurse to all healthcare professionals and senior leadership. The days of patients and nurses following a physician’s order without favor to care has now loaned themselves to more of an interdisciplinary approach to practice. Though, it is encouraged that the patient makes decisions for themselves, after receiving the proper education and information on their condition. Part of the patient-centered care is to be the patients’ advocate, by letting them know you are there for them when they are unable to speak and advocate for themselves and what is in their best interest. That goes in hand with educating them on “self-management of care, health literacy, patient, and family education through nurse-patient communication and interaction (Finkelman & Kenner, 2016, p. 271).”

This paper seeks to expand upon the 2010 Institute of Medicine’s report on the future of nursing, leading change, advancing health and illustrating its impact on nursing education, practice and leadership. There is an ongoing transformation in the healthcare system necessitated by the need to achieve a patient centered care in the community, public, and primary care settings in contrast to previous times. Nurses occupying vital roles in the healthcare system, need improvements in the areas mentioned above to

Coordinating Primary Care/Team Effort: “patient Centered Medical Home” Geisinger calls it “Personal Health Navigator” aims to help patients manage all the complexities of their care in one setting. Focus on putting patients/families at the center of care. Doctors, nurses, technicians and case managers (who coordinates it all). Constantly

Berry, L., Rock, B., Houskamp, B., Brueggeman, J., & Tucker, L., (2013). Care coordination for patients with complex health profiles in inpatient and outpatient settings. Mayo Clinic Proceedings, 88(2), 184-94. Retrieved from http://search.proquest.com/docview/1312503895?accountid=34574

xi). The IOM stressed that “nurses have key roles to play as team members and leaders for a reformed and better-integrated, patient-centered health care system” (IOM, 2011, p. xi).

There are many way in which nurses could contribute leadership to improve the health care system to provide advance patient care. IOM states that, “serving as strong patient advocates, nurses must be involved in decision making about how to improve the delivery of care” (IOM, 2011, p. 222). In order to have a voice in the health care reform, nurses need to take opportunities to be involve in committees or board meetings and participate in making policies. The IOM “committee believes there will be numerous opportunities for nurses to help develop and implement care

Effective communication among professionals from different disciples is key area to care coordination (Joint Commission on Accreditation of Healthcare Organizations, 2007) however; Communication involves a variety of strategies and purposes (Kripalani et al, 2007). In an interprofessional collaboration, different professional groups work mutually as a team to develop a positive impact on health care. As said by Zwarenstein, Goldman & Reeves (2009) collaborative working is improved because of an agreement between different professionals through communication. Good communication is vital as It enables health care professionals to build relationships

One of the aims of the Patient Protection and Affordable Care Act (ACA) of 2010 is improved integration and coordination of services for primary patient care. The patient-centered medical home (PCMH) is one of the approaches by which improvements can be established. The patient-centered medical home model is particularly well-suited for people who have chronic illness. The design of the patient-centered medical home model departs substantively from traditional reimbursement policies, in that, the ACA provides for incentives and resources to enable care coordinators to be directly recognized and compensated for their care coordination work. Care coordinators are most often registered nurses who through their work that aligns with ACA engage in quality improvement work, cost-effectiveness measures, and patient advocacy. To bring the ACA model to a human scale, the authors present a case study of a care coordinator at a patient-centered medical home in rural Maine. The table provided below provides a basic textual analysis of the study as it is published in the professional nursing journal.

According to American Nurses Association (2010) Scope and Standards of Nursing Practice, collaboration is defined as, “a professional healthcare partnership grounded in a reciprocal and respectful recognition and acceptance of: each partner’s unique expertise, power, and sphere of influence and responsibilities; commonality of goals; the mutual safeguarding of the legitimate interest of each party; and the advantages of such a relationship”.(p. 64). Collaboration amongst health care providers is very crucial in providing quality care to patients. Integration of disciplinary teams, improves communication, coordination, and most importantly, the safety and quality of patient care. It provides interaction between team members allowing

Healthcare reform in the United States (U.S.), continues to be a hot topic in the news. Whether it discusses how the program will be financed, the need to redesign the organization, or how the process of delivering healthcare will be implemented; one thing that is a frontrunner, is the need for registered nurses (RNs) and advanced practice registered nurses (APRNs) to fill the increased demands on the primary care system (Institute of Medicine, & Robert Wood Johnson Foundation, 2011, p. 375). “Several programs and initiatives included in the health reform legislation involve interdisciplinary and cross-setting care coordination and care management services of RNs” (Institute of Medicine, & Robert Wood Johnson Foundation, 2011, p. 377).

Working in a team is an important responsibility by understanding each other’s role which may include doctor, nurse, occupational therapist, physiotherapist and many more. Team members divide the work based on their scope practice such as acute care, metal health care, homecare etc. Interprofessional collaboration practice is decision making and communicating between individuals for their patient’s health based on their knowledge and skills. It helps to promote habits, maximizing health resources, leading care to be safer with patient’s satisfaction and Canada’s health care (Kenaszchuk, Reeves, Nicholas, & Zwarenstein, 2010).

I agree with you Maricela, nurses ultimate goal is to provide patient centered high quality care. Last six years, I have seen many changes in my hospital to create patient-centered, improve the coordination of care, engage patients as partners in decision-making, and improve quality of care and patient satisfaction. Our focus is on evidence base practice. We are using SBAR communication, answer call light with in five ring, bedside reporting incorporating patient and family at the end of shift report to improve our patient satisfaction score. Patients are getting education regarding their diagnosis, medications and prevention of the diseases. We are trying to reduce hospital readmission, hospital acquired infection or pressure ulcer. We give

A patient centered medical home (PCMH) could integrate patient care. A patient centered medial home is a team of healthcare providers coming together to improve the health of a specific population. A PCMH is designed to integrate primary care and specialists into improve care coordination, safety and quality.(Stange, et al 2010) A PCMH would also improve physician training and development to provide a commitment to treat the whole patient, rather than just one part.(Stange, et al 2010) Healthcare fragmentation can also be limited through improved communication between providers using e-mail and social media tools such as facebook and twitter.

“The ACA outlines some new health care arrangements, and with these structures will come new opportunities for new roles. Nurses have the opportunity to play a central role in transforming the health care system to create a more accessible, high-quality, and value-driven environment for patients. If the system is to capitalize on this opportunity, however, the

“All health care disciplines share a common and primary commitment to serving the patient and working toward the ideal of health for all.” (American Association of Colleges of Nursing, 2014, p. 1) There are many different professional members in the healthcare system. Each of them, have a specific specialty and responsibility to the patient and play an important role in the patient’s overall plan of care. “The scope of health care mandates that health professionals work collaboratively and with other related disciplines. Collaboration emanates from an understanding and appreciation of the roles and contributions that each discipline brings to the care delivery experience.” (American Association of Colleges of