- Care coordination is an essential nursing practice that employs nurses to improve communication between patients, families and the healthcare team for safer patient care. - Nurses design effective care plans to improve health outcomes and coordinate care among the team and other stakeholders. - The presentation aims to raise nurses' understanding of care coordination principles and ethical decision-making while implementing patient-centered strategies.

1. Care Coordination Presentation
Care Coordination Presentation
Good afternoon, everyone! My name is ………., and I am a
registered nurse here at UMass Memorial. Care Coordination is
an essential practice of primary care that employs nurses to
bridge the gap between the patients, their families, and the
healthcare team for a safer patient care practice. Nurses design
more effective care plans to improve the health outcomes of the
patients and coordinate such plans among the health care team
and other concerned people for the coordination and continuity
of care. Nurses are obligated to implement a continuum of care
that follows an ethical framework and consumes all the
resources optimally for the welfare of patients. This
presentation aims to raise nurses' understanding of the
fundamental principles of care coordination and ethical
decision-making while implementing effective strategies for
patient-centered care.
Effective Strategies for Collaborating with Patients
Patient care involves a team-based care plan that includes
collaborating with medical care staff and the patient's family
members. The agenda is to raise awareness about the disease
among all the concerned people. All the nursing staff members,
health professionals, specialists, paramedic staff, the patient's
family, and the patient himself should be part of this team. The
main aim of this team-based care plan is the availability of
effective and safer care to the patients (Poitras et al, 2018). The
agency presents two main strategies that might prove helpful for
better outcomes. Both strategies involve collaboration with
patients' families.

2. The first strategy comprises wider approaches, including team-
based care that involves all the concerned people in the health
care department for patient-centered care, reconciling
medication to ensure better patients outcomes, a coordinated
care administration, use of Information technology that creates
better communication among the health care facilitators and
patients thus promoting the quality of care.
The second strategy following particular care coordination
involves designing a coordinated care plan for the patients,
allowing proper communication and education of the patients,
determining the patient's requirements and reaching health
goals, assisting with care transition, implementing proper
monitoring and follow up plans, promoting patients’ health
goals and including community resources into the plan.
As indicated by the researchers at Johns Hopkins University,
nurse-guided primary care has improved the health outcomes for
community organizations. This model involves a specially
educated nurse. The nurse takes a preliminary assessment of the
patient, collaborates with other health care facilitators,
determines the patients' needs, involves the health specialist,
and follows a highly coordinated care plan (Haas et al., 2019).
Guided care can save up to 11% on total health care expenses
and limit hospital re-admissions, thus providing safe, effective,
and inexpensive care to the patients.
Change Management and Patient-Centered Care
The health care team needs to make changes in health
management to ensure the patients' involvement in their health
care plan. They are supposed to guide the patients properly
about the disease and advise them on specific adjustments to
improve their health. The health care providers used to apply
facts and logic, insisting the patients follow a health care plan
which was usually ignored on the part of the patients (Bergerum
et al., 2019). This was followed by a reprimand being repeated
by the physician. This tactic never worked in improving the
health of the patients. The need is to change the attitude of the
whole care management and care plan. The research has shown

3. that instead of arguing or forcing the patients to follow the
health care plan, it is needed to go for more patient-centered
approaches. Health professionals should question the patients to
think of ways of improving their health and make a plan
themselves, assess the barriers encompassing their ways, and
suggest a more appropriate and suitable plan (Poitras et al,
2018). This tactic has paved the path to achieving health care
goals.
Care coordination and guided care plan have brought positive
changes to the health care system. Making the patients a part of
their team and transmitting essential knowledge to the patients
enhances the patient's involvement. This increases the patients’
satisfaction and guarantees effective care provision to them
(Chen et al., 2020). Coordinated care planning has been shown
to improve the quality of care.
Ethical Decision Making and Coordinated Care Plans
Nurses are supposed to have complete knowledge of ethical
principles to impact patient care from the ethical aspect. A
nurse having a better understanding of ethical decision-making
can influence the health care team accordingly. A nurse must
keep a balance between autonomy and beneficence for the
establishment of an effective care plan. The aim is to respect
the patients' rights and allow them to make decisions on their
own regarding their treatment (Bergerum et al., 2019). The
ethical care coordination plan demands the active involvement
of the patients. Moreover, the American Nurses Association
Code of Ethics directs the nurses to speak for the patients'
rights. Nurses stand for the patients in the execution of the care
plan and advocate for their rights even if it goes against the
opinions of other team members.
Cultural aspects are also considered in the ethical care
coordination plan. Cultural sensitivity and acceptance are one of
the evidence-based practices that help understand how different
patients belonging to different cultures behave in particular
situations. This involves complete acquaintance of other
cultures and acceptance on the side of the health care provider

4. (Bergerum et al., 2019). Such behavior provides a peaceful
environment for effective care. Understanding about patient's
culture enables healthcare facilitators to adopt a better
healthcare approach for the patient. They can console them well
in case of any gloomy situation and guide them about the next
plan of action. Respecting other cultures is important. It creates
a sense of acceptance and rapport among the patients and health
care providers. Nurses must have a basic understanding of how
different cultures interact to avoid any dynamic
misinterpretation.
Healthcare Policy Provisions on Outcomes and Patient
Experiences
“Patient Protection and Affordable Care Act has played a
significant role in improving the health care system” (Chen et
al., 2020). Research shows that following Affordable care act
policies facilitate patients. Patients would have greater access
to a coordinated care plan, facilitate continuity of effective care
and limit re-admissions if the health care policies are put in
action effectively. It's been researched that countries with
coordinated care plans and proper health management systems
have better patient outcomes and save the health budget for
other welfare (Chen et al., 2020). Taking preventive measures
before the health problems worsen and following after-care
precautions can reduce the mortality rate and lower re-
admissions of treated patients. This can reduce the burden on
the health care departments, and they can focus on the smaller
number of patients more attentively.
Conclusion
A vital part is played by the nurses in care coordination and
continuum of care. Patient-centered care plan based on patients'
preferences and needs results in better patient outcomes. Along
with the awareness of health care policies, nurses must be
culturally competent. They must have a better acquaintance with
other cultures. This allows them to provide effective treatment
to patients belonging to diverse backgrounds having different
cultures and social values. This impacts the nurse's care

5. coordination plan keeping ethical aspects into consideration.
The nurses should allow patients to make decisions about
treatments and choose the most suitable care plan. Nurses are
supposed to educate the patients about the disease and possible
adjustments they can bring in their routine plan to cope with the
pertaining illness. They should avoid dictating them. Instead,
they should involve them in making a carefully coordinated plan
that suits their routine and is easy to follow.
References
Bergerum, C., Thor, J., Josefsson, K., & Wolmesjö, M. (2019).
How might patient involvement in healthcare quality
improvement efforts work—a realist literature review. Health
Expectations, 22(5), 952–964.
https://doi.org/10.1111/hex.12900
Chen, C.-C., & Cheng, S.-H. (2020). Care continuity and care
coordination: A preliminary examination of their effects on
hospitalization. Medical Care Research and Review, 78(5), 475–
489. https://doi.org/10.1177/1077558720903882
Haas, S., Swan, B. A., & Jessie, A. T. (2019). Care
coordination: Roles of registered nurses across the care
continuum. Nursing Economics, 37(6), 317–322.
Poitras, M.-E., Maltais, M.-E., Bestard-Denommé, L., Stewart,
M., & Fortin, M. (2018). What are the effective elements in
patient-centered and multimorbidity care? a scoping review.
BMC Health Services Research, 18(1).
https://doi.org/10.1186/s12913-018-3213-8
Assignment 4: Clinical Hour and Patient Logs
Assignment Instructions:
· I need 16 small individual psychotherapy clinical notes (one
paragraph), each note should include: CC, small mental status,
and progress achieved during the visit. Please review the below
example, doesn’t have to exactly as the example but close

6. enough.
· Student Notes- Students must include a brief
summary/synopsis of the patient visit—this does not need to be
a SOAP note; however, the note needs to be sufficient to
remember your patient encounter
· Can be adult male or female age between 18 to 65, with any (1
or more) of the following diagnosis:
Example:
(Fem, -49 Mood Disorder, Anxiety Disorder)
49-year-old patient with depressive disorder associated to
monetary problems due to the loss of one of her jobs, patient
has only a part time position. Patient is here today for a follow -
up consultation. The patient said, “I’m feeling better, I’m not so
concerned about my late payments, since I start the financial
help”. In today's consultation session, the patient appears
awake, alert, and oriented x 4. Dressed well with good hygiene
and good eye contact. She presents with spontaneous speech
normal rate and volume, relevant, coherent. Mood is a little
anxious. Affect is mood congruent. Thought process is
concrete. Thought content is linear and coherent. Patient
reported that she had been performing all the activities to
further decrease depression. Patient showed improvements in
mood, which was the main objective to achieve this week. The
patient's mood has continually improved for the past three
weeks. The symptoms of depression have decreased, as per
patient’s reports crying less, and improving her sleep time. The
patient was encouraged to continue with follow-up
psychotherapy. Individual psychotherapy and follow up
scheduled next week to continue improving the patient's
condition.
Develop a 20-minute presentation for nursing colleagues

7. highlighting the fundamental principles of care coordination.
Create a detailed narrative script for your presentation,
approximately 4-5 pages in length, and record a video of your
presentation.