NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project NURS-FPX 6618 Leadership in Care Coordination ​​​​​​​Purpose of Planning and Presenting a Care Coordination Project

NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project

NURS-FPX 6618 Leadership in Care Coordination

Purpose of Planning and Presenting a Care Coordination Project

This assessment focuses on developing a care coordination project plan for chronic care patients in the Virginia community. Elderly people in this community suffer from chronic diseases, resulting in higher comorbidities and mortalities. The quality of care provided to chronic disease patients lacks adequate coordination, leading to poor health outcomes in elderly patients. Hospital readmission rates are increasing daily due to poor management of chronic conditions like diabetes, hypertension, renal diseases, and chronic obstructive pulmonary disease.

Moreover, medication error rates are rising in chronic care patients due to a lack of coordination among healthcare professionals. As a care coordinator project manager at Sentara Northern Virginia Medical Center, I am developing a care coordination project plan for the described population, which requires care coordination from multiple organizations. This care coordination plan will help the elderly population with chronic conditions manage their condition with a coordinated and patient-centered care approach.

Vision of Interagency Coordinated Care for Chronic Care Patients

The primary vision of interagency coordinated care for chronic care patients is patient-centered and collaborative care, prioritizing the overall well-being of the elderly population with chronic conditions. This is possible by integrating a multidisciplinary team of healthcare professionals, including physicians, nurses, pharmacists, social workers, dietitians, etc. The care coordinating teams will enable effective care delivery through adequate coordination and collaboration, leaving no room for errors or treatment delays.

Effective sharing of patient health data among healthcare professionals is necessary. This can be done using healthcare technologies such as electronic health records, which enhance smooth coordination and communication as they can be integrated into multiple organizations (Southerland et al., 2020). A patient-centered care approach can be delivered in several ways, from onsite follow-ups to online consultations via telehealth technology. By leveraging technology, healthcare providers can give consolidated care remotely, and patients can receive coordinated care in the comfort of their homes.

Furthermore, patient-centered care clinics can be established for this population, serving as a central point for chronic patients. This will provide consolidated care to chronic care patients from physical, mental, and emotional perspectives (Corazzini et al., 2019). Additionally, healthcare professionals must be provided with ongoing training and educational programs to gain the necessary skills and knowledge to deliver consolidated care with improved quality to treat chronic conditions. This will pave a constant roadway for healthcare professionals to provide continuity of care for chronic care patients.

Underlying Assumptions and Areas of Uncertainty

The underlying assumption of this vision is that healthcare professionals can overcome barriers to collaboration and eradicate fragmented care by working together and coordinating care in the best interest of patients. Moreover, with advancements in healthcare technologies, healthcare professionals can share patient data and enable care coordination. The trained healthcare workforce can find better ways to provide consolidated care. However, uncertainties in fulfilling this vision pertain to various factors, such as stagnant behaviors of patients, inadequate healthcare teams, resource limitations, and interoperability challenges (Gunnarson, 2022). These areas of uncertainty must be considered while developing and implementing a care coordination plan for the affected population.

Mandatory Organizations and Groups to Participate in Care

Several organizations and groups must participate to provide consolidated and holistic care for chronic disease patients. These identified organizations that must contribute to improving coordinated care for chronic patients include “Virginia’s Department of Health,” “Virginia’s Association of Area Agencies on Aging,” and national healthcare organizations such as the “American Heart Association (AHA),” “American Diabetes Association (ADA),” and “American Nursing Association (ANA).” The Virginia Department of Health advocates for the prosperity of public health, including care for chronic patients. They have worked on various initiatives to prevent chronic diseases and manage them effectively (Virginia Department of Health, n.d.).

Therefore, the