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

Name

Capella University

NURS-FPX 6618 Leadership in Care Coordination

Prof. Name

Date

Planning and Presenting a Care Coordination Project

As the Care Coordinator Project Manager at Tampa General Hospital, I am excited to present a comprehensive care coordination project plan tailored for chronic care patients. This initiative aims to streamline and enhance the integration of services across multiple organizations, ensuring cohesive and patient-centered care. By leveraging local, state, and national resources, we strive to improve health outcomes and the quality of life for this vulnerable population.

Purpose of Presentation

This care Coordination Plan outlines a strategic framework for managing and integrating care for chronic care patients at Tampa General Hospital. This presentation aims to secure the support of administrative decision-makers by demonstrating the need for a coordinated approach that enhances patient outcomes, reduces healthcare costs, and improves overall patient satisfaction. By addressing gaps in care and fostering collaboration among various healthcare providers, we seek to establish a seamless, efficient, and effective care delivery system for our chronic care patients.

Vision of Interagency Coordinated Care for Chronic Care Patients

Our vision for interagency coordinated care for chronic patients at Tampa General Hospital involves creating a seamlessly integrated network of healthcare providers and community organizations to deliver comprehensive, patient-centered care. We envision a centralized care coordination hub within the hospital as the primary point of contact for patients, healthcare providers, and community organizations. This hub will oversee and manage all care coordination efforts, ensuring seamless communication and efficient care management. Interdisciplinary care teams, comprising primary care physicians, specialists, nurses, social workers, pharmacists, and mental health professionals, will collaboratively develop and implement individualized care plans tailored to each patient’s needs (Pascucci et al., 2020).

To facilitate this vision, we plan to implement an integrated electronic health record (EHR) system accessible to all participating organizations, allowing real-time sharing of patient information for timely and informed decision-making. Additionally, patient navigators will assist chronic care patients in understanding their treatment options, scheduling appointments, and accessing community resources. In contrast, support services of telehealth options will address barriers to care. Regular interagency meetings and case conferences will be scheduled to discuss patient progress, update care plans, and address challenges, promoting a culture of continuous learning and improvement through shared insights and best practices (Kaasbøll et al., 2020).

Underlying Assumptions and Areas of Uncertainty

Our vision rests on several key assumptions, including a commitment to collaboration among all participating organizations, the effective adoption and use of the integrated EHR system, the availability of sufficient resources, and the willingness and ability of patients to engage with the care coordination hub and support services. However, there are areas of uncertainty, such as potential challenges in aligning different organizational policies, procedures, and cultures, ensuring data security and privacy, the long-term sustainability of the initiative, and variability in patient compliance with care plans (Pinho & Reeves, 2020). By proactively addressing these assumptions and uncertainties, we aim to build a robust and effective care coordination system that significantly enhances the quality of life for chronic care patients.

Mandatory Organizations and Groups to Participate in Care

Caring for chronic care patients at Tampa General Hospital necessitates the active participation and collaboration of several key organizations and groups. Florida’s Department of Health will be crucial in providing regulatory guidance, public health data, and resources to support statewide initiatives for chronic disease management. The National Association of Chronic Disease Directors (NACDD) offers strategic support and advocacy to help shape policies and programs that address chronic disease prevention and control (National Association of Chronic Disease Directors, n.d.). National organizations such as the American Heart Association (AHA) and the American Diabetes Association (ADA) will contribute valuable expertise, educational resources, and evidence-based guidelines for managing cardiovascular diseases and diabetes, respectively. The American Nursing Association (ANA) will ensure that nursing practices align with the highest standards of care and support ongoing professional development for nurses involved in chronic care (Powers et al., 2020).

Analyzing the environment and provider capabilities reveals a complex landscape with strengths and challenges. Tampa General Hospital has a robust infrastructure and a skilled multidisciplinary team that delivers high-quality care. However, effective care coordination requires overcoming barriers such as disparate health information systems, variations in organizational policies, and resource constraints. Florida’s Department of Health can facilitate data sharing and alignment of public health initiatives with hospital programs. The NACDD can assist in developing comprehensive care strategies and fostering interagency collaboration.

The AHA and ADA provide critical disease-specific knowledge and patient education materials, enhancing the hospital’s ability to deliver specialized care. The ANA’s focus on nursing excellence ensures that care delivery is compassionate, competent, and patient-centered. The interprofessional care coordination team will comprise primary care physicians, specialists, nurses, social workers, pharmacists, mental health professionals, patient navigators, and administrative support staff. This comprehensive approach will ensure that chronic care patients receive holistic, coordinated, and effective care, ultimately improving health outcomes and quality of life (Prestel, 2021).

Determining Resource Needs of the Population

Operational and Capital Budgeting Needs

A detailed assessment of resource needs is essential to effectively manage and coordinate care for chronic care patients at Tampa General Hospital. General supplies such as glucose monitors, blood pressure cuffs, insulin pumps, medication organizers, wound care supplies, and telehealth devices will be necessary to support ongoing patient management. Educational materials, including printed and digital resources on chronic disease management, nutrition guides, and exercise plans, will be provided to empower patients with knowledge. Technological investments in tablets or laptops for telehealth appointments, software for remote monitoring, and upgrades to the electronic health record (EHR) system are also crucial (Modi & Feldman, 2022).

Staffing will include additional primary care physicians, specialists such as endocrinologists and cardiologists, nurses, social workers, patient navigators, dietitians, physical therapists, and mental health professionals. Administrative support will be bolstered with care coordinators, IT support for EHR management, and administrative assistants for scheduling and follow-up. Capital purchases will focus on upgrading technology, enhancing facilities with dedicated spaces for interdisciplinary team meetings and telehealth consultations, and acquiring vehicles for home health visits and patient transportation services (Modi & Feldman, 2022).

Costs: Estimated Funds

The estimated annual budget for these resources is approximately $3.7 million, including $200,000 for general supplies, $1.5 million for staffing, and $2 million for capital purchases. This budget is based on assumptions such as serving an estimated 5,000 chronic care patients, maintaining adequate staffing ratios, ensuring technology adoption by providers and patients, and securing funding from hospital budgets, grants, and partnerships with public health organizations and non-profits. Uncertainties in patient engagement, funding stability, technology integration, and potential policy changes must be addressed proactively. By carefully considering these resource needs and planning for possible challenges, Tampa General Hospital aims to establish a sustainable and effective care coordination program that significantly enhances chronic care patients’ health outcomes and quality of life (Lite et al., 2020).

Project Milestones and Outcome Measures

The project to enhance care coordination for chronic care patients at Tampa General Hospital is structured around several key milestones and outcome measures to improve patient outcomes, operational efficiency, and overall care quality. Within the first three months, our primary milestone involves establishing a fully operational interprofessional care team comprising primary care physicians, specialists, nurses, social workers, and support staff, with comprehensive onboarding and training to ensure alignment with care coordination protocols.

By the sixth month, we will implement a unified electronic health record (EHR) system, a pivotal step in enhancing data accessibility and continuity of care across disciplines. Concurrently, within the initial four months, we will develop and initiate personalized care plans for all patients, integrating medical, social, and behavioral health goals to optimize treatment outcomes. Regular monthly interagency meetings and case conferences will be integral, facilitating ongoing collaboration and adjustment of care plans based on patient progress and feedback (Kaasbøll et al., 2020).

Outcome Measure for Care Coordination

One critical outcome measure for our project at Tampa General Hospital is reducing hospital readmissions and emergency room visits related to chronic conditions. We aim to significantly decrease readmissions within the first year of implementing the care coordination initiative. This measure reflects our commitment to improving patient outcomes and reducing healthcare costs by ensuring patients receive comprehensive and continuous care management. By closely monitoring and evaluating readmission rates, we aim to identify areas where interventions can be strengthened, such as through better discharge planning, patient education, and follow-up care coordination. Success in this measure will enhance the quality of life for chronic care patients and contribute to our institution’s overall efficiency and sustainability of healthcare delivery (Myers et al., 2020).

Presentation of Project Plan to Administrative Decision-Makers

Successful implementation of care coordination for chronic care patients hinges on integrating a patient-centered approach with multidisciplinary collaboration. This necessitates fair resource allocation and engagement with pertinent stakeholders. Achieving milestones within designated timelines will depend on cohesive collaboration, with participation from various organizations, to secure financial support and ensure coordinated care delivery. Ongoing evaluation of project outcome measures will be conducted to confirm the attainment of desired goals.

By implementing a robust care coordination framework, we aim to improve health outcomes for chronic care patients and reduce hospital readmissions and emergency room visits through better disease management, medication adherence, and timely interventions. Streamlining care processes and enhancing communication among healthcare teams and external partners will lead to better resource utilization and cost savings over time. Personalized, coordinated care will increase patient satisfaction by ensuring that their needs are met comprehensively and consistently across different healthcare settings (Myers et al., 2020).

Questions about staffing requirements and workload distribution are addressed through planned adequate staffing levels and comprehensive training and resources for our team. Concerns about integrating new technology, such as the EHR system, will be mitigated by selecting a system aligned with our needs and providing thorough staff training to facilitate a smooth transition and maximize benefits. Anticipated questions and alternative viewpoints include inquiries about the project’s impact on patient wait times and access to care, to which we respond that improved care coordination will reduce wait times and enhance timely interventions, ultimately improving patient outcomes and satisfaction.

Conclusion

In conclusion, the proposed care coordination project at Tampa General Hospital is designed to significantly enhance the management and outcomes for chronic care patients. By fostering multidisciplinary collaboration, leveraging advanced technology, and ensuring comprehensive patient-centered care, we aim to improve health outcomes, reduce hospital readmissions, and elevate patient satisfaction. This strategic approach addresses the complex needs of chronic care patients while promoting operational efficiency and cost savings, ultimately contributing to a sustainable and high-quality healthcare delivery system. Your support for this initiative will be pivotal in realizing these goals and transforming the care experience for our chronic care patients.

References

Kaasbøll, J., Ådnanes, M., Paulsen, V., & Melby, L. (2020). Interagency collaboration for early identification and follow-up of mental health problems in residential youth care: Evaluation of a collaboration model. Nordic Social Work Research, 1–16. https://doi.org/10.1080/2156857x.2020.1833964

Lite, S., Gordon, W. J., & Stern, A. D. (2020). Association of the meaningful use electronic health record incentive program with health information technology venture capital funding. JAMA Network Open, 3(3), e201402. https://doi.org/10.1001/jamanetworkopen.2020.1402

Modi, S., & Feldman, S. S. (2022). The value of electronic health records since the health information technology for economic and clinical health act: Systematic review. JMIR Medical Informatics, 10(9), e37283. https://doi.org/10.2196/37283

Myers, L. C., Faridi, M. K., Hasegawa, K., Hanania, N. A., & Camargo, C. A. (2020). The hospital readmissions reduction program and readmissions for chronic obstructive pulmonary disease, 2006-2015. Annals of the American Thoracic Society, 17(4). https://doi.org/10.1513/annalsats.201909-672oc

National Association of Chronic Disease Directors. (n.d.). NACDD. https://chronicdisease.org/page/about_nacdd/

Pascucci, D., Sassano, M., Nurchis, M. C., Cicconi, M., Acampora, A., Park, D., Morano, C., & Damiani, G. (2020). Impact of interprofessional collaboration on chronic disease management: Findings from a systematic review of clinical trial and meta-analysis. Health Policy, 125(2). https://doi.org/10.1016/j.healthpol.2020.12.006

Pinho, D. L. M., & Reeves, S. (2020). An interprofessional international research collaboration: exploration of key opportunities and challenges. Journal of Interprofessional Care, 35(1), 1–5. https://doi.org/10.1080/13561820.2020.1711716

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

Powers, M. A., Bardsley, J. K., Cypress, M., Funnell, M. M., Harms, D., Hess-Fischl, A., Hooks, B., Isaacs, D., Mandel, E. D., Maryniuk, M. D., Norton, A., Rinker, J., Siminerio, L. M., & Uelmen, S. (2020). Diabetes self-management education and support in adults with type 2 diabetes: A consensus report of the American Diabetes Association, the Association of Diabetes Care & Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAS, the American Association of Nurse Practitioners, and the American Pharmacists Association. Journal of the American Pharmacists Association, 60(6), 1–18. https://doi.org/10.1016/j.japh.2020.04.018

Prestel, C. (2021). Candida auris outbreak in a COVID-19 specialty care unit — Florida, july–august 2020. MMWR. Morbidity and Mortality Weekly Report, 70. https://doi.org/10.15585/mmwr.mm7002e3