NURSING BS-FPX-4050 Capella University – What effective strategies of care coordination with patients and their families to achieve desired health outcomes?


What effective strategies of care coordination with patients and their families to achieve desired health outcomes?

Identify the aspects of change management that directly affect elements of the patient experience essential to provision of high-quality, patient-centered care

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Rationale for coordinated care plans based on ethical decision making.

Identify the potential impact of specific health care policy provisions on outcomes and patient experiences.

Give basic information on care coordination and continuum of care and the nurse’s role in these.


 Enhancing Health Outcomes: Strategies for Care Coordination and Change Management in Patient-Centered Care


Care coordination plays a pivotal role in achieving desired health outcomes and improving the patient experience. This essay explores effective strategies for care coordination with patients and their families, the aspects of change management that influence elements of the patient experience, the rationale for coordinated care plans based on ethical decision making, the potential impact of health care policy provisions on outcomes and patient experiences, and the nurse’s role in care coordination and the continuum of care.

Strategies for Care Coordination

 Effective Communication: Open and clear communication between healthcare providers, patients, and their families is essential (O’Daniel, 2008). This involves active listening, establishing rapport, and sharing information in a way that is easily understood and accessible.

Comprehensive Care Planning: Collaboratively developing care plans that address the individual needs and goals of patients and their families. This includes setting realistic expectations, identifying potential barriers, and involving patients in decision-making processes.

Care Team Collaboration: Facilitating interdisciplinary collaboration among healthcare professionals to ensure seamless transitions, shared responsibilities, and consistent delivery of care. This includes regular team meetings, care conferences, and care coordination tools.

Health Information Technology: Utilizing electronic health records, telehealth, and other digital platforms to improve communication, access to information, and coordination among healthcare providers, patients, and families.

 Patient and Family Engagement: Actively involving patients and their families in care decisions, goal setting, and self-management (O’Daniel, 2008). This includes education, shared decision-making, and providing resources to support their active participation in their own care.

 Change Management and the Patient Experience

Change management directly affects elements of the patient experience essential to the provision of

Communication: Effective change management ensures transparent and timely communication regarding changes in care delivery, policies, and procedures. This fosters trust and engagement among patients, families, and healthcare providers.

Education and Training: Providing comprehensive education and training to healthcare providers to equip them with the knowledge and skills needed to implement changes successfully. This promotes consistency in care delivery and minimizes disruption to the patient experience.

Patient-Centered Approach: Incorporating patient perspectives, preferences, and feedback throughout the change process. This ensures that changes align with patient needs and values, enhancing the overall patient experience.

Continuity of Care: Ensuring smooth transitions during periods of change by maintaining continuity of care. This involves effective handoffs, care coordination, and communication among healthcare providers and settings.

Rationale for Coordinated Care Plans based on Ethical Decision Making

Coordinated care plans based on ethical decision making promote patient autonomy, beneficence, and justice. Such plans:

Respect Patient Autonomy: Coordinated care plans involve patients in decision-making processes, allowing them to express their preferences, values, and goals. This upholds their right to participate actively in their care and make informed choices.

Promote Beneficence: Coordinated care plans ensure that all necessary healthcare services and interventions are appropriately and efficiently provided to achieve optimal health outcomes for patients. This aligns with the ethical principle of doing good and maximizing patient well-being.

Enhance Justice: Coordinated care plans help address healthcare disparities and promote equitable access to quality care (Varkey, 2020). By coordinating services, healthcare professionals can allocate resources effectively and provide equitable care to all patients, regardless of their socio-economic background or geographic location.

 Impact of Health Care Policy Provisions on Outcomes and Patient Experiences

Specific health care policy provisions can have a significant impact on outcomes and patient experiences. For example:

Access to Care: Policies that improve access to care, such as expanding insurance coverage or reducing barriers to healthcare services, can lead to better health outcomes and improved patient experiences by ensuring timely and affordable access to needed care.

 Care Coordination: Policy provisions that support care coordination efforts, such as incentivizing interdisciplinary collaboration or implementing health information exchange systems, can enhance patient outcomes by promoting seamless transitions, reducing duplication of services, and improving communication among providers.

 Patient-Centered Care: Policies that prioritize patient-centered care, such as incorporating patient perspectives in quality measurement and payment systems, can lead to better patient experiences and improved outcomes by aligning care with patient preferences, values, and goals (Kominski et al., 2017).

 Care Coordination and Continuum of Care: The Nurse’s Role

Nurses play a crucial role in care coordination and the continuum of care. Their responsibilities include:

Assessing patient needs, preferences, and goals to develop individualized care plans and coordinate services accordingly.

Facilitating communication and collaboration among healthcare providers, patients, and their families to ensure seamless transitions and continuity of care.

Educating patients and families about their conditions, treatments, and self-management strategies to promote active participation in care.

Advocating for patients’ rights, preferences, and access to quality care within the healthcare system.

Monitoring patient progress, evaluating outcomes, and making necessary adjustments to the care plan to optimize health outcomes.


Effective care coordination strategies, supported by change management principles, can contribute to improved health outcomes and enhanced patient experiences. Ethically grounded coordinated care plans uphold patient autonomy, beneficence, and justice. Health care policy provisions can significantly impact outcomes and patient experiences, emphasizing the importance of policies that prioritize access, care coordination, and patient-centered care (Kominski et al., 2017). Nurses play a vital role in coordinating care and ensuring the continuum of care, promoting holistic, patient-centered approaches that optimize health outcomes and patient satisfaction.


Kominski, G. F., Nonzee, N. J., & Sorensen, A. (2017). The Affordable Care Act’s Impacts on Access to Insurance and Health Care for Low-Income Populations. Annual Review of Public Health, 38(1), 489–505. 

O’Daniel, M. (2008, April 1). Professional Communication and Team Collaboration. Patient Safety and Quality – NCBI Bookshelf. 

Varkey, B. (2020). Principles of Clinical Ethics and Their Application to Practice. Medical Principles and Practice, 30(1), 17–28. 

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