NURS FPX 4065 Assessment 4 Care Coordination Presentation to Colleagues

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Capella University

NURS-FPX 4065 A4

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Care Coordination Presentation to Colleagues

Hi, I’m ______. In this presentation I will discuss how the principles of care coordination can positively affect the outcomes of the people I care for as a nurse and how effective collaboration with other professions, change management, ethics in decision making and utilisation of provisions in health policies can help make this a reality. Domestic or intimate partner violence (IPV) is one of the most complex needs to care for. Care coordination is essentially a nurse coordinating the care of a patient with their family, the community and their healthcare providers; it is a safety and patient-centred care (Baek et al., 2023). As we learn more about generation through these principles this will help to improve our understanding of how to create continuity of care and will help us to achieve better quality outcomes.

Strategies for Collaborating with Patients and Their Families

The patient and family work is based on the idea of planning and intervening in the “place” the patient/family is, rather than meeting the patient/family at their “place. The trauma-informed approach of nurses in relation to domestic violence should be focused on ensuring that the person who is the victim of the violence feels safe and secure. In the trauma approach to care (trauma-informed care concept) the development of a relationship is guided by trust and understanding of how patients react to trauma and how trauma can be re-activated during screening and follow-up. Trauma-informed care includes relationship-building based on trust and knowledge of typical trauma responses and how these may be re-triggered during screening and follow-up. When communicating with care, the nurses will be expected to listen, to be non-judgemental, active and reassuring.

Education activities should be coordinated for the specific drug. Generally, IPV victims develop anxiety, depression or sleep disorders which can be treated with drug therapy. Nurses should be aware of drug interactions and teach patients about the effects and usage of some drugs, such as the selective serotonin reuptake inhibitors (SSRIs) or anxiolytics. Medication reconciliation and teaching will result in fewer adverse reactions, and better adherence to the medication (Ford-Gilboe et al, 2024). Nurses should also encourage the patient and family to be involved in the discussion about the medication so that there is a feeling of caring and trust in the nurse and decisions about the medication can be made in conjunction with the patient/ family.

Also, one needs to be ‘culturally competent’. Most IPV survivors are influenced by a variety of cultural backgrounds and beliefs about illness, past illness experiences, and help-seeking. It can be done with the help of family members: Make sure that care plans include one family member to ensure cultural appropriateness, and safety planning, to address cultural norms of privacy and patient preferences of the family.

The nurses can empower the patients and their families with decision-making and motivational interviewing. This helps them to communicate their vision and choices for the intervention and involve them in the plan (Webb 2024). A safe housing plan, sharing the patient’s story with the support group member (selected by the patient) or with the patient as the patient’s chosen advocate, can result in a collaborative care climate, better care plan outcomes and adherence to a care plan.

Aspects of Change Management

The experience of care co-ordinating is a big part of change management if the patient is concerned and talking about it. The next step in the implementation process – the acceptance and implementation of interventions into practice – can be followed based on the systematic review and the application of the systematic change models (e.g., Kotter’s ‘Eight-Step Change Model’). If you do need to put a screening and referral process for IPV in place, for instance, you need to have training, coordination and feedback in place so that this patient is reminded continually of the importance of doing this, but not pressured to do it, while at the same time you are making sure that you are doing it.

It’s a change process, and you need to be clear and consistent in your communication. The clients will have a number of different types of care units, including primary care, counselling and community shelters. They will reduce the number of misunderstandings between a patient’s care members and build trusting spaces by making patients and care members aware of the change processes (e.g., via a new screening tool or a new pathway) that are being implemented. (Chu et al., 2023) Individuals can use the same communication devices, and this helps them during transitions and helps minimise any errors during transition, etc.

There is also increased opportunity for co-operative change, which is likely to result in increased patients’ engagement. This participation will increase survivors’ and families’ interest and involvement in self-care, creation of care policies (Safety Planning or Linkage system between resources and families) (Hamid Ravaghi et al., 2025). In the long term, the patients will undoubtedly enjoy better health; in the short term, care coordination will make them feel valued and will increase the therapeutic alliance as they will immediately feel useful and important in the care coordination process. Top of Form

Rationale for Coordinated Care Plans

Ethical decision-making is the foundation and key element of effective care for victims of IPV in creating coordinated care plans. One of the critical elements of coordinated care is ‘beneficence ‘, which involves taking an active response to potential further abuse and trauma, and to lack access to support services (Chu et al., 2023). It extends respect to autonomy, which is a fundamental principle of medical ethics, involves the patient in the decision-making process, and does not make decisions for the patient; it also does not have a paternalistic attitude towards patient-centred care. Often, fair and equitable distribution of resources and culturally responsive interventions can help to promote justice. A safe, effective and responsive nursing practice can be achieved if the patient’s perspective is taken into consideration when giving care ethically and the needs of the people who are victims of IPV are recognised both physically, psychosocially and culturally.

Implications and Consequences

The moral aspect of the role of organised care in relation to the IPV victims is also worth considering – organised co-operation may ensure the safety and well-being of the patient and enable him to gain power. The nurses expand opportunities to ensure the best supportive care of the survivors – trauma-informed counseling, safety planning and psychosocial support. Structured risk assessment is vital in assisting the nurse to identify unsafe situations, to educate the family about safety, and to incorporate legal and psychological supports to aid in the recovery process. Conversely, an unethical approach (such as failure to address cultural needs and less than optimal safety planning, etc.) can result in harm, traumatization, less than optimal health outcomes, and greater health care costs. This will facilitate a living continuum of care for the survivors, using the lens of care ethics, care planning, and equality of services.

Assumptions

Each coordinated care plan has implicit assumption(s) that impact decision-making. Some of the assumptions are as follows: Patients would want to be a part of the Care. Most of them do, and engagement could vary, with some, due to stress and trauma, preferring to be directed to first place to start Bujold et al., 2022). A difference like this would allow a nurse to encourage an engagement strategy that is more suited to their own set of learners as opposed to a ‘one size fits all’ method. The second assumption is that when managed appropriately, the social determinants of health, “fair care” will occur. Some of these factors that can affect access and continuity of care are the issue of income security, transportation, and cultural beliefs. Care planning needs to be based on the assumption that the determinants need to be included in, and not be a stand-alone element of, care planning. The care plans will not be effective if they are not based on the assumptions, which should be reviewed.

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Impact of Specific Health Care Policy Provisions

The level of co-ordinated care provided and used will vary based on services a health care policy can offer. An important new extension of coverage and added focus on how to provide preventive care under the Affordable Care Act (ACA) allows for early detection and stepped-up actions with IPV victims. This will remove the need for people to pay a portion of their expenses for having screening or counseling services, and will make access to the services needed much easier, especially for the vulnerable population (Johns & Rosenthal, 2024). It’s already impacted the coordination, too, due to value-driven care models, which will reward better care outcomes, rather than services rendered. Since their introduction, they have lowered the readmission rate, helped achieve better rates for chronic diseases, and increased rates of patient satisfaction. Regarding the IPV survivors, it means having the structures to spend time on multidisciplinary coordination, referral, and follow-up, adding to the continuity and security of the survivors.

Contrasting this, however, the case for expanding Medicaid results in reduced out-of-pocket costs for people in most states when it comes to their primary health care and behavioral health services, and advocating for the reimbursement limitation isn’t in the best interests of sustaining the system of care coordination. Reimbursement may also be an ethical dilemma about access and equity – some providers may not be as motivated to serve Medicaid patients in an area if they can get reimbursed because of Medicaid’s reimbursement rates. The three policies (equal access, care safety, and quality provision) are encouraged by the coordinated care provision, and gaps in policy implementation are a hindrance, but the three nurses are able to overcome these by asserting their policies and working ethically.

The Nurse’s Vital Role in the Coordination and Continuum of Care

The most important element in coordinated care is the nurses! Nurses are involved in identifying needs, educating the family and patient, communicating in various care settings, and assisting with resolving discrepancies in care and services in the community. The nurses would be first responders and play a crucial role in detecting signs of IPV, screening, and safety planning should the person be a victim of IPV (Adams et al., 2022). They provide referral services to counselling, legal, and shelter services and also provide support groups for the patients to give them complete care. Some interdisciplinary work (led by a nurse) also takes place. Working together with nurses and social workers, the community, the pharmacist, the mental health worker, and the physician helps nurses to plan for their patients’ needs. They ensure that a smooth step-out of hospital, into follow-up in the community, is made in order to reduce the risk for patients and boost their confidence. Important to note that in health facilities, the patients’ representative is a nurse (Karam et al., 2025).

Conclusion

Nurses play a key role in the outcomes, determined by their collaborative working practice with the patient and their families, their effective use of change management, ethically based care planning, and informed use of health policy provisions. The combination of evidence-based practice, cultural competence, and trauma-informed care is the way of ensuring that care delivery is respectful and effective. Elements of all of this can happen any time we provide care as a nurse — we can help someone to traverse a growing and more complicated care chain, and provide equity and continuity in the care chain.