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Assessment 1: Planning and Presenting a Care Coordination

Project

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Student Name

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Capella University

mNURS-FPX 6618 Leadership in Care Coordination

Prof. Name
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MAR 24, 2024
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Purpose of Planning and Presenting a Care
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Coordination Initiative
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This assessment aims to develop a comprehensive plan for a care coordination initiative
targeting chronic care patients in the Virginia community. Within this community, elderly
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individuals face the burden of chronic diseases, resulting in elevated comorbidities and
mortality rates. Unfortunately, the quality of care provided to these patients often lacks
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sufficient coordination, leading to adverse health outcomes and increased hospital

readmission rates. Moreover, medication errors are on the rise due to inadequate
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collaboration among healthcare professionals. As the Care Coordinator Project

Manager at Sentara Northern Virginia Medical Centers, I am spearheading the
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development of a care coordination project to address these challenges and provide a

patient-centered approach for managing chronic conditions in the elderly population.
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Vision of Collaborative Care for Chronic Care Patients

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The primary vision of this initiative is centered around patient-centric and collaborative
care, prioritizing the overall well-being of elderly individuals with chronic conditions.
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Achieving this vision entails integrating a multidisciplinary team of healthcare

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professionals, including physicians, nurses, pharmacists, social workers, and dieticians.

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Through effective coordination and collaboration, these teams will ensure the delivery of
high-quality care, minimizing errors and treatment delays.

Central to this vision is the seamless sharing of patient health data among healthcare
professionals, facilitated by healthcare technologies such as electronic health records
(EHR). These technologies enhance communication and coordination by allowing for
the integration of patient data across multiple organizations. Additionally,
patient-centered care will be delivered through various channels, including onsite
follow-ups and online consultations via telehealth technology, enabling patients to
receive coordinated care from the comfort of their homes.

Establishing patient-centered care clinics will serve as a hub for chronic care patients,

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offering comprehensive care from physical, mental, and emotional perspectives.
Furthermore, continuous training and educational programs will be provided to
healthcare professionals to equip them with the necessary skills to deliver consolidated

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care effectively. This will ensure a continuous pathway for healthcare professionals to
provide consistent care to chronic care patients.

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Underlying Assumptions and Areas of Uncertainty

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While the vision of collaborative care is promising, there are underlying assumptions
and areas of uncertainty that must be acknowledged. The assumption is that healthcare
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professionals can overcome barriers to collaboration and provide coordinated care in
the best interest of patients. However, uncertainties such as patient behaviors, resource
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limitations, and interoperability challenges may pose challenges to achieving this vision.
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Mandatory Organizations and Groups to Participate in Care

Several organizations and groups must participate in providing consolidated care for
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chronic disease patients. These include Virginia’s Department of Health, Virginia’s

Association of Area Agencies on Aging, and national healthcare organizations such as
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the American Heart Association, American Diabetes Association, and American Nursing
Association. These organizations play vital roles in advocating for public health and
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providing guidelines for managing chronic conditions.

Identified Members of Interprofessional Care Coordination Team

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The interprofessional care coordination team will consist of primary care physicians,
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nurses, pharmacists, social workers, dieticians, case managers, telehealth specialists,

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community health workers, health educators, and mental health specialists. These team
members will collaborate to provide comprehensive care to chronic disease patients.

Analysis of Environmental and Provider Capabilities

Environmental factors such as healthcare policy, funding, and technology infrastructure,

along with provider capabilities such as interprofessional collaboration and access to
health information technology, significantly impact care coordination for chronic care
patients.

Determining Resource Needs of the Population

Resource needs for delivering coordinated care to chronic care patients include general

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supplies, staffing, capital purchases, and funds for training and education. These
resources are essential for ensuring the effective delivery of care to the target
population.

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Project Milestones and Outcome Measures

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Key milestones for the care coordination project include stakeholder engagement,
resource allocation, program establishment, staffing and training, care planning and
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coordination, and continuous monitoring and improvement. Outcome measures include
clinical health outcomes, healthcare utilization, and patient satisfaction.
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Presentation of Project Plan to Administrative Decision-Makers
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Successful implementation of the care coordination initiative requires integration of a

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patient-centered approach with multidisciplinary collaboration. Equitable resource

allocation and engagement with stakeholders are crucial for achieving project goals and
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desired outcomes.

Conclusion
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In conclusion, the care coordination project for chronic care patients aims to address the
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challenges of fragmented care and poor health outcomes. Through collaborative efforts
involving various organizations and healthcare professionals, a patient-centered
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approach will be adopted to provide comprehensive care to the elderly population with
chronic conditions.
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References:
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Conway, A., O’Donnell, C., & Yates, P. (2019). The effectiveness of the nurse care
coordinator role on patient-reported and health service outcomes: A systematic review.
Evaluation & the Health Professions, 42(3), 263–296.

Corazzini, K. N., Anderson, R. A., Bowers, B. J., Chu, C. H., Edvardsson, D., Fagertun,
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Gunnarson, M. (2022). Disclosing the person in renal care coordination: Why

unpredictability, uncertainty, and irreversibility are inherent in person-centred care.
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Khatri, R., Aklilu Endalamaw, Erku, D., Eskinder Wolka, Frehiwot Nigatu, Zewdie, A., &
Assefa, Y. (2023). Continuity and care coordination of primary health care: A scoping

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review. BMC Health Services Research, 23(1).

Miller, L. B., Sjoberg, H., Mayberry, A., McCreight, M. S., Ayele, R. A., & Battaglia, C.

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(2019). The Advanced Care Coordination Program: A protocol for improving transitions
of care for dual-use veterans from community emergency departments back to the

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Veterans Health Administration (VA) primary care. BMC Health Services Research,
19(1).
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Southerland, L. T., Stephens, J. A., Carpenter, C. R., Mion, L. C., Moffatt-Bruce, S. D.,
Zachman, A., ... & Caterino, J. M. (2020). Study protocol for IMAGE: Implementing
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multidisciplinary assessments for geriatric patients in an emergency department

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observation unit, a hybrid effectiveness/implementation study using the consolidated

framework for implementation research. Implementation Science Communications, 1(1).
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Virginia Department of Health. (n.d.). Chronic disease prevention and health promotion
collaborative. [Online]. Available: https://www.vdh.virginia.gov/collaborative/.
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