Coordinated Care in Nursing Homes


The federal government through the Affordable Care Act introduced the need for care coordination among older adults to promote equity, reduced provider burnout, reduced costs, enhanced care experience, and improved patients outcomes (Dreyer, 2014). Care coordination is defined as a methodical approach of care that enhances communication between patients, service providers and family caregivers (Fahey et al., 2003). A well designed coordinated model result in efficient care improves outcomes and optimizes support systems for seniors and their families. The community of choice for this assessment is nursing homes that take care of the needs of seniors. The assignment will explore on use of coordinated care in nursing homes and ethical and policies that affect the delivery of coordinated care into this community. 

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According to Bollig et al. (2015), 60% of the elderly population has multiple chronic illnesses. Introducing coordinated care min nursing homes improve health outcomes. According to Bollig et al. (2015), nursing homes face varying ethical challenges including resident’s privacy and behavior, cooperation, and communication between the health professionals and the resident’s family, decision-making capacity and autonomy, lack of resources, use of restraints, and end-of-life issues. The coordinated care among seniors requires the application of a holistic and patient-oriented strategy which is stipulated in the principles of Patient-centered medical home (PCMH). 

Government Policies on Nursing Homes

The seniors in nursing homes face three major problems increased the cost of care, the quality of nursing care is suspected and the inaccessibility of nursing homes among seniors (RAND, 2019). In the majority of states, nursing homes are regulated by the integration of state (Department of Health) and federal authorities (Human Services Centers for Medicare and Medicaid Services in the US {CMS}) (RAND, 2019). The major purchaser of nursing homes in the US is Medicaid as they reimburse nursing home services. One ethical issue facing nursing home administrators is reimbursed where they argue more Medicaid patients can be admitted if Medicaid increases the return on Medicaid patient care.

The US government has introduced the Patient Protection & Affordable Care Act (ACA). The National Coalition on Care Coordination (N3C) was formed by the ACA to provide promotes comprehensive care coordination for older adults. The policy requires health professionals to follow a patient-centered approach by integrating the patient, the family, and other caregivers. Besides, the N3C allows the inclusivity of patients, family and health providers bridging gaps in care, includes multiple social support and community providers and provides the appropriate level of care (Philips, 2016). 

Nursing homes provide lifestyle maintenance and rehabilitation services to the seniors among seniors who either rely on Medicaid for payment or those who pay for their services. According to RAND (2019), the cost of care and the capacity of nursing homes is regulated by the Certificate of Need (CON) cost-containment program. This program limits the entry of new nursing homes and the expansion of the existing ones. However, the level of quality received by Medicaid patients and private pay is similar as regulated by the CON. State regulation plays a vital role in nursing homes as it provides licenses to the services. Also, the nursing homes are subject to federal government regulation including the Health Insurance Portability and Accountability Act (HIPPA).

Health Insurance Portability and Accountability Act (HIPAA) and seniors

The role of HIPPA in coordinated care among the elderly with multiple chronic illnesses is to protect the privacy of patients. According to Barnett (2019), seniors are required to sign the HIPAA to authorize their caregivers to access health information. The benefit of HIPAA is that it ensures that the personal information of the senior is secure and confidential. However, before granting access to the resident’s information, HIPAA requires communication between health professionals, family, and residents. Also, the family pays and discusses medical bills with health professionals. The policy allows the caregiver with an understanding of the complexity of the resident’s condition to make a decision.

Nursing homes face ethical issues following HIPPA guidelines. The objective of HIPAA is to ensure a patient’s information is private. Areas covered by HIPAA include electronic medical records, billing companies, health plans, non-patient care employees, students, and all persons working in healthcare facilities. However, some data is excluded from HIPAA policy; infectious diseases, child/elderly abuse, injuries sustained in crimes, stab wound, and gunshot wounds (Edemekong et al., 2019). Therefore, any elderly person within this criterion is excluded from HIPAA privacy rules. 

National, State, and Local Policy and Care Coordination

National Policy

The federal government requires all nursing homes to undergo national inspection to record the daily care received by the seniors. However, the actual inspection is carried out by state federals that provide a recommendation to the state officials (Artiga and Hinton, 2019). The national officials have the power to fine non-compliant nursing homes. One of the severe fines probable to nursing homes from the federal government is the failure to pay for Medicaid and Medicare programs. The verdict means that the nursing home cannot admit new residents as long as the fine is not waved. Worse, the nursing home is prone to suspension from the Medicaid and Medicare program.

ACA requires nursing homes to participate in Medicaid and Medicare. Failure to participate in ACA programs makes it challenging for nursing homes to penetrate in the health systems. Also, failure to participate in federal programs challenges the entry of geriatric care managers (GCMs) to the “new” health system (Jennings, 2016). It is challenging to predict the involvement of the federal government in nursing homes due to the diverse care coordination programs. However, the Medicare programs for the elderly will likely change in five years in terms of reimbursement. The GCMs are required by the federal government to promote coordinated care through a holistic approach and integration in the care system by integrating.

Local and State Policy 

The ACA introduces the Community-Based Care Transitions Program (CCTP) whose role is to improve the care transition process from hospitals to nursing homes, save Medicare funds, and reduce readmission rates to hospitals (ACA, Sec. 3026). The community-based organizations are a result of local policies where ACA collaborates with facilities with high readmission rates and includes many stakeholders including consumers. Another policy is the Center for Medicare and Medicaid Services (CMS) which is responsible for patient/ caregiver self-management support, promotes timely patient interaction with post-acute care providers, and initiates post-discharge education. The states are allowed by the ACA Sec. 2703 to establish nursing homes.

Impact of the Code of Ethics for Nurses on the Coordination and Continuum of Care

Parento (2012) defines health disparity as differences in any health-related factors including access to care, health behaviors, quality of life, and response to treatment, diagnosis and disease burden. Some of the factors that cause health disparities among seniors include quality and access of care, culture, education, geographic location, identity and expression, disability status, social-economic status, ethnicity, race, biological factors, health behavior, and others. For example, the incidence of Alzheimer’s disease is more prevalent among Hispanics and African Americans than other ethnic groups. Another factor affecting the aging population is environmental factors like wealth, income, education, retirement, work, social mobility, immigration, and residential segregation.

The core goal of healthy people 2020 is to eliminate disparities and attain health equity. The seniors are one population facing health inequities due to the factors discussed above. This has led to the integration of the Affordable Care Act (ACA) with the Healthy People 2020 initiative to improve public health, care coordination, and insurance coverage. The healthy people 2020 in nursing homes can be attained by embracing health promotion strategies among persons at risk of multiple chronic illnesses (Koh, Blakey and Roper, 2014). For example, seniors who are overweight require walking or doing other exercises to remain healthy and prevent diabetes and other obese related conditions.

The healthy people 2020 program is facilitated by social justice and philosophical reasons including human rights principles to health which require the human capability to fully function in their day to day activities. This principle among seniors call for an increase in the availability of home- and community-based services, increase of prevention programs for falls, increase in the availability and accessibility of behavioral health care, increase in the availability and accessibility of dental services for seniors, increase the accessibility of clinical preventive services among seniors, and enhances primary care (Parento, 2012). The code of ethics facilitates the introduction of the Health and Aging Policy Fellows Program which supports mobility of seniors in nursing homes


Artiga, S., & Hinton, E. (2019). Beyond health care: the role of social determinants in promoting health and health equity. Health20, 10.

Barnett, K. (2019). How HIPAA Impacts Caring for Aging Parents. [online] Available at: [Accessed 26 Nov. 2019].

Bollig, G., Schmidt, G., Rosland, J. and Heller, A. (2015). Ethical challenges in nursing homes – staff’s opinions and experiences with systematic ethics meetings with participation of residents’ relatives. Scandinavian Journal of Caring Sciences, 29(4), pp.810-823.

Dreyer, T. (2014). Care transitions: best practices and evidence-based programs. Home Healthcare Now, 32(5), 309-316.

Edemekong, P., Haydel, M., Slowik, J., Sharma, S., & Dalal, B. (2019). Health insurance portability and accountability act (hipaa). StatPearls.

Fahey, T., Montgomery, A. A., Barnes, J., & Protheroe, J. (2003). Quality of care for elderly residents in nursing homes and elderly people living at home: controlled observational study. Bmj326(7389), 580.

Jennings, L. A., Tan, Z., Wenger, N. S., Cook, E. A., Han, W., McCreath, H. E., … & Reuben, D. B. (2016). Quality of care provided by a comprehensive dementia care comanagement program. Journal of the American Geriatrics Society64(8), 1724-1730.

Koh, H., Blakey, C., & Roper, A. (2014). Healthy People 2020: A Report Card on the Health of the Nation. JAMA311(24), 2475. doi: 10.1001/jama.2014.6446

Parento, E. W. (2012). Health equity, healthy people 2020, and coercive legal mechanisms as necessary for the Achievement of both. Loy. L. REv.58, 655.

Phillips, C. (2016). Care coordination for primary care practice. J Am Board Fam Med29(6), 649-651.RAND. (2019). Government Policy and the Cost and Quality of Nursing Homes. RAND Corporation.

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