Nursing Care Coordination Case Study

The role of nurse practitioner is valuable when discussing collaborative care. There are so many levels of care, so many health entities, and so many insurer criteria involved that it is instrumental to have a role that can work towards help bring all aspects together. In addition to diagnosing, treating, and managing care, the role of the nurse practitioner is to manage simple and episodic acute health issues along with chronic disease (Sangster-Gormley, Martin-Misener, & Burge, 2013). It is important to note that although this is a function of this role, nurse practitioners also practice from a holistic point of view which allows them to help manage patient conditions or wellness in a more complete fashion. This includes helping patients have access to care beyond primary and secondary care settings. This encourages nurse practitioners to work alongside other health care and allied health professions, and families to create an individualized plan for every patient (van

Patient-centered care refers to the view that patients and their family members are partners in developing a care plan. This stems from the belief that the patient is in control and that the care provided is rooted in respect that addresses the patient’s personal needs and values (Barnsteiner & Sherwood, 2012). Creating a partnership with a patient that allows them to grasp the goals and methods of their plan of care and includes them in the decision-making process can prevent errors from occurring. This gives the patient the opportunity to correct any

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

Care coordination is key in the new value-based healthcare market. Poor follow-up care plans often lead to readmission penalties and decreased patient satisfaction evaluations. Before, if a patient sought care in an urgent care center, that information may have never made it back to the patient’s

So it is extremely important that the RN and other team member have a two-way open dialog to ensure that the necessary information is obtained. When team members come together in such a collaborative way, it promotes an atmosphere that allows discussions that can solve complex client health care problems, prevent errors, and allows the RN to act as an advocate for the client. In the plan of care when the RN is continuously reviewing the chart and client status, this collaboration is critical. It allows the RN to ensure that all disciplines involved in the clients care are up to date and doing their part to contribute to the expected goals. In most situations it is the responsibility of the RN to organize these collaborations when they believe a client could benefit from

Some of the likely direct benefit of better coordinated care would be; reduction in the need for acute care services such as hospitalizations and over utilization of emergency room. Developing coordinated medical homes to prevent, diagnose and treat disease early will save health care cost. Also, CMS estimates shows that, 45 percent of hospitalizations of dual eligibles from either Medicare skilled nursing facilities or Medicaid nursing facilities in 2005 could have been avoided if health care are well

A collaborative approach, as an essential component of patient care, is emerging as best practice in recent literature. A review of the literature reveals that there is a common interchanging of the terms Patient and Family-Centered Care (PFCC), Family-Centered Care (FCC), and Patient-Centered Care (PCC). Although researchers interchange these terms often, there are commonalities that can be identified. General common principles include; information sharing, respect and honoring differences, partnership and collaboration, negotiation, and care in the

As we talked, we discussed the questions as outlined in the assignment starting with patient-centered care, barriers that may hinder it, and how it can be improved. She defined patient-centered care as “The patient being involved in their care. The patient needs to feel they are empowered to ask questions regarding their care, tests, medications, and any consultation that may be scheduled.” She stated that while at our facility our staff did a “great job” accommodating patient and family cares, comforts, and concerns. We agreed, there are times that barriers prevent fully supportive patient-centered care such as, doctors who refuse discuss patient care or concerns, short staffing, and when care management is disorganized. This can be improved by encouraging

Multidisciplinary rounds approach calls for various members of the medical profession to synchronize individual skills, knowledge, and expertise in order to provide quality care for patients (IHI, 2015). The team members consist of nurses, physicians, “ancillary clinicians, and staff” (IHI, 2015, p.4). Each member contributes to the care of the patient individually, but in a cohesive manner (IHI, 2015). The multidisciplinary rounds care model strongly encourages and utilizes parental involvement during rounds (IHI, 2015). Multidisciplinary rounds also solicit parents and family members to communicate with the care team care as well as care team communications concerning the patient to the family (IHI, p.4). For each patient, the rounds are conducted daily (IHI, 2015). For each patient, goals are set daily (IHI, 2015). This ensures daily communication among care team and with patient and the families of the patient (IHI, 2015). The idea is to establish good coordination of care; thus, making safe and efficient care more consistent (IHI, 2015). As the protocols or the guidelines are clearly communicated among care teams, risks are identified, and staff are educated, the quality of health care improves (IHI, 2015).

Care coordination is an integral part of current health care models, including the Patient Centered Medical Home Model. There are various sources that show the benefit of care coordination efforts in improving

As a result, there must be one person to coordinate the team. Often, this is the case manager (Hood, 2014). The purpose of this interdisciplinary collaboration is to identify the best treatment plan and care to meet the patient’s needs (Fewster-Thuente, 2015). Key in this collaboration is the patient, making sure they approve their plan of care. “Including patients and families in the collaboration is imperative because harmony cannot be achieved and the plan cannot go forward without their consent” (Fewster-Thuente, 2015, p. 359).

function of pediatric primary care that may be best delivered using a team approach. Coordination of care is a holistic health care approach that is often delivered by a team of practitioners such as a physician, advanced practice nurse, school nurse, social worker, pharmacist, nutritionist, respiratory therapist, and others. Coordination is defined as “the state of being harmonized in a common action or effort” (Stille & Antonelli, 2004). The cases of Dewey Jones, Martha Ames, and Spike Smith are examples of interdisciplinary coordinated care.

Care coordination within health care systems ensures the client of an effective and short stay. Care coordination refers to the coordination between and among professional teams that serve valuable roles involved in providing care to clients. Different disciplines of health care professionals include nursing, medicine, case management, pharmacy, nutrition, social work, and allied health professionals, such as speech therapists and physical therapists. They are found in all health care delivery systems and are extremely effective when the focus is strictly on the needs of the client. Interprofessional teams are valuable because each health care professional has specialized knowledge and skills so that health care plans are determined with

In order to collaborate successfully with the other members of the team, they have to ‘work together’. Collaboration implies “working together to achieve something that neither agency could achieve alone” (cited by Biggs in Day, 2006, p9). It involves effective communication and contribution to a common goal – and the health and wellbeing of the patient and shared responsibility of the outcome. Each team requires a quality leader, regular meetings attended by all members, joint assessment, regular reviews of patient records which should include ‘shared care plans’; joint decisions following consultation and task delegation to individual team members with the outcome being that “care must be structured, organised and systematically provided to each person in a variety of ways” (Creating an Interprofessional Workforce, 2007, p10).

Teamwork is vital in healthcare.  When all participants are engaged in a program, goals are successfully achieved. Being able to communicate and work collectively as a team requires an appreciation for each other’s area of practice.  Every team member has an important role and being acknowledged provides a sense of responsibility and accountability. Essentially, inter-professional collaboration helps ensure that the patient is getting care that is not only accessible but also comprehensive.  The plan of a patients’ care includes active participation by all health care professionals working interdependently in accordance to the patient’s preferences, values and beliefs. The health care team accomplishes the goal of meeting the patient’s medical needs by delivering evidence-based practice.   To deliver quality care, the patient should always be involved.