Fundamental Principles of Care Coordination

Care coordination is a beneficial model that tackles medical and non-medical interventions like social and psychological factors. The current health care system in use in the United States is coordination and continuum of care irrespective of the diversity and market demand. The introduction of care coordination to the community will not only demystify the complex health system for patients, but will also allow providers to improve patient satisfaction, reduce healthcare costs, and improve population health. As nurses, while developing and designing the care coordination program, we should consider the following the fundamentals of care coordination. 

The first element to consider in defining the care coordination model is health care management strategy. In every system, there is a need to include a strong population health management strategy that will aim at improving the health of the community and reduce health disparity. Nurses should include core guiding principles to be used by all health personnel in the hospital. Another element to consider is the development of a patient-centered model. According to WHO (2018), a patient-centered care model includes both the medical and non-medical needs of the patient. The nurses require being well equipped with sufficient resources that will assist in the delivery of direct care to the patient and their family. The personalized approach includes assessment of patient’s issues, social and medical needs, and an efficient strategy to solve the issue.

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The third element nurses require to consider is the implementation of tools for care delivery. Due to the need for an interdisciplinary team, the model requires the implementation of suitable organizational and clinical support to promote shared decision making. To ensure patient-centered care, health professionals require communicating and sharing the decision to promote quality and individualized care. Also, effective care coordination requires the use of telemedicine or electronic health records to communicate among health professionals to identify care opportunities and track patient’s information. Implementation of tools in the delivery of care increase patient engagement as they can easily access their health records. 

The fourth element or principle to consider is continuity care. According to Menear et al. (2016) coordinated and continuity in care are intertwined during and after the health visit. Continuity encompasses both medical and non-medical services like dietary assistance and housing regimes for the homeless. Continuity in coordinated care originates from multiple aspects of a health care system including social services agencies, hospitals, nursing homes, and health plans.

Another significant principle is accountability and health assessments. As nurses, it is essential to conduct periodical assessments as it provides a whole picture of the issue and the risks facing the patient. Zaidi (2019) explains that comprehensive assessments allow health providers to attain a whole picture of the patients’ needs and allows the patient to benefit from crediting and payers incentives. Coordinated care requires nurses to improve the transition of care to reduce the rate of readmission. The introduction of the Affordable Care Act and Medicare payments has introduced policies against reimbursements in case of readmissions. To avoid this, nurses should effectively communicate with patients and families during the transition of care. The health facilities play a vital role in care transitions through the alignment of accountability and financial incentives among specialists, primary care, and nurses.

Interdisciplinary care teams (ICTs) are fundamental in coordinated care. Some of the personnel to include in the team include physicians, nurses, support team, pharmacists, nutritionists, the patient’s caregiver, and the patient. The ICTs role is to comprehensively solve the patient’s issues and meet their needs through an individualized approach. The team will allow nurses to work with other health workers and share skills, knowledge and expertise to comprehensively solve the health issue.

Lastly, nurses require applying case management techniques through the development and refinement of stratification methodologies. Zaidi (2019) explains that one core element of care coordination is risk stratification. All programs in the model should be based on changing care outcomes by targeting the population at risk. Some of the populations to target include children with chronic conditions, seniors with multiple chronic diseases, the homeless or persons under substance abuse. Health cost in the US has increased tremendously calling for a need to reduce cost through care coordination which reduces readmission rate. Thus, the stratification of high-risk populations is essential for ineffective and coordinated care.

Collaborating With Patients and Families

Nurses and other healthcare professionals care for patients in a stressful, inefficient and complex environment. Menear et al. (2016) explain that the health care environment is poorly integrated due to culture, incentives, and structure. This opens the need for engaging the patent and the family in the patients’ illness journey. According to Menear et al. (2016) integrated care among patients, providers, payers, and caregivers results in improved economic outcomes, the experience of care, health and care outcomes. The collaboration between patients, families and health professionals follows a patient-centered approach.

An optimal care model allows health professionals to provide essential advice and information on intervention and treatment options based on medical evidence. Also, the patient and the caregiver provide the health professional with personal knowledge of their condition. The two sources of information are essential in formulating the best strategies. However, the process is ‘time-consuming and complex and not attractive to many health personnel. Nonetheless, a focus on the patient is fundamental in coordinated care during every step in the pathway. Communication is significant to initiate collaboration of patients and caregivers with health professionals.

Aspects Change Management

A patient-centeredness model results in positive benefits to the providers’ financial performance, satisfaction among health professionals and clinical outcome. This section will explore the clinical outcomes where according to McGinnis et al. (2013) patient engagement in the delivery of care improves emotional health, increases physical recover, and reduces pain and discomfort fast. Another changing aspect is that it reduces long term complications and readmission to hospitals. Understanding one’s condition promotes adherence to treatment management. Another aspect of change management is that the model promotes adherence to complex treatment regimens and personal health maintenance. This is because the model increases the trust of patients towards health professionals and increases the knowledge of nurses about the patient.

Ethical Issue and Policy Implication

Care integration among all disciplines is hastened by the introduction of telemedicine. However, telemedicine can transform patient-centered care as health providers communicate with patients through mobile devices apps, email, or text. It can integrate remote monitoring and sensing mechanisms through automatic reminders and interactions with patients outside the health facility. However, the use of telemedicine results in ethical issues on whether to forgo the face to face encounters which increase therapeutic value through the doctor-patient relationship.

The introduction of the Health Insurance Portability and Accounting Act (HIPAA) introduced laws that protect the privacy of patients’ information (Randel et al., 2001). Nurses face ethical dilemmas while dealing with patients’ information in the coordinated care model. According to Randel et al. (2001), violating the confidentiality of a patient may cause mistrust with patients and may also result in ethical and legal consequences. Nurses require familiarizing themselves with HIPAA during coordinated care as the policy provides guidelines on information to share with a third party and the confidential information. One ethical issue regarding patient confidentiality policies is that withholding the condition of a patient may cause more harm to the patient or others (for example a spouse with HIV) making it unethical. 

The major ethical issue is the threat of patients’ privacy in the coordinated care model. This is because the patient may be unaware of how to share personal medical information and with whom. Coordinated care increases the venues for security breaches due to technological advances like EHR and telemedicine. The current health policies in the hospitals fail to identify who is responsible in case of privacy concerns. The operational challenges of the coordinated care model require the adoption of new encryption and security tools to protect personal information. To counter this, there is a need to formulate a robust privacy and security plan to increase the confidence of patients in coordinated care and protect personal information. Informed consent is essential during coordinated care as some patients may prefer care from centralized health personnel. It is essential to provide all relevant information to the patient and seek consent before any procedure.


McGinnis, J. M., Stuckhardt, L., Saunders, R., & Smith, M. (Eds.). (2013). Best care at lower cost: the path to continuously learning health care in America. National Academies Press.

Menear, M., Gervais, M., Careau, E., Chouinard, M., Cloutier, G., & Delorme, A. et al. (2016). Strategies and impacts of patient and family engagement in collaborative mental healthcare: protocol for a systematic and realist review. BMJ Open6(9), e012949. doi: 10.1136/bmjopen-2016-012949

Randel, L., Pearson, S., Sabin, J., Hyams, T., & Emanuel, E. (2001). How Managed Care Can Be Ethical. Health Affairs20(4), 43-56. doi: 10.1377/hlthaff.20.4.43

WHO. (2018). Continuity and coordination of care. World Health Organization.Zaidi, H. (2019). 8 Strategies to Build a Care Coordination Model that Works. COPE Health Solutions

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