Planning and Presenting a Care Coordination Project

 Slide 2:  Hello, my name is ______. I will present the structure of the care coordination project for further improvement. Based on interview responses of the care coordinator project manager of Harmony Health Network, this plan aims to use an integrated, patient-centered care system to meet the complex needs of patients under chronic care delivery (Nankya et al., 2022). With technological integration, this system aims to develop a more holistic, enduring, and personalized approach to patient management through increased cooperation between social workers, physicians, and community support services. The overall aim is to offer the care coordination strategy to the administrative decision-makers in a persuasive, clear, and rational way so that they can approve this strategic care plan.

Purpose of Care Coordination Plan

Slide 3:  The purpose of the practice of coordinated care is to improve the outcome of Patients with Chronic care by effectively and systematically planning patient treatment and care (Winter et al., 2024). This approach also enhances accessible healthcare technologies, social service provisions, and community resources through the efficient use of advanced communication technologies for the benefit of the patient while reducing readmission rates to the hospitals and distinctively enhancing the patient’s quality of life.

Vision of Interagency Coordinated Care

Slide 4: A thorough and efficient care delivery model that connects the networks of social support and healthcare service delivery is being transformed by the suggested idea of care coordination for chronic patients. This system will be built to go through what is known as an integration system, which will combine hospitals, social services, primary care physicians, specialists, and community organizations. It will also use cutting-edge technology to facilitate communication and share data regarding the needs of clients for care (De et al., 2022). The active monitoring of patient progress through the use of electronic health records (EHRs) and the regular meetings of various professionals to review and revise treatment plans for patients—including the utilization of telehealth services to improve accessibility and flexibility of patient care—are fundamental components of current practice.

Organizing and Consolidating Care

Slide 5: The present study also aims to enhance the exchange of information among caregivers who deal directly with the patients, and therefore a framework for the organization of effective and efficient patient care coordination for persons with chronic care conditions will be designed. This will involve the making of a contract on information sharing between the agencies as well as central care coordination which will state care mapping procedures (Winter et al., 2024). Such standardized patterns as care teams, designating care coordinators for particular patients, and daily multidisciplinary team conferences are the cornerstones that offer orbed, telemedicine care collaboration and emanation across all levels of healthcare. Also, since new technology and care coordination are complex concepts for other healthcare professions, education and training will be taught.

Assumptions and Areas of Uncertainty

The commitment of each contributing organization to work together and collect data, adequate funding to support these staff and technologies information, and patients and their families are based on several fundamental assumptions (Winter et al., 2024). However, there is still a mindset of clinical professionals, the challenge of dealing with patient care across many organizations existing with different network assets, and the requirement for training to optimize the mode of delivery which they still affect.

Organizations and Groups Involved in Coordinated Care 

Slide 6: To improve the way that patients with chronic diseases are managed; this calls for the promotion of the formation of several organizations/groups capable of handling these patients. Patients seeking health care services directly: Some of the key actors include Kaiser Permanente, Mayo Clinic, Cleveland Clinic, and additional primary care physicians, specialists, nurses, and nurse practitioners (Nankya et al., 2022). Besides other centralized emergency services, outpatient and inpatient wards of hospitals and clinics are very important in providing significant treatments. The operations of food and housing, transportation, and Social service organizations play a major role in helping the American Red Cross manage the social determinants of health. Such services with referenced visiting nurse groups are important for additional care and recovery (Dubas et al., 2023). Currently, patient advocacy organizations include the likes of the American Heart Association, the National Diabetes Association, and many other patient support organizations that provide support to patients and their families.

Interprofessional Care Coordination Team

Slide 7: Research focuses on the application of PCP and EBP for healthcare organizations, by examining the key elements in the attempt to achieve balance between the two important paradigms in the administration of organizations in the field of healthcare. Researches focus on goals in care and how this can be applied to implement the chronic care model, underlining the importance of aligning healthcare services to the patient’s health goals to improve results (García et al., 2022). Patient care must be provided by personnel with diverse expertise in their field. The care coordinators are mainly responsible for each patient’s case and all the related contacts in the Harmony Health Network. The first-care physicians and specialists consist of those from the Cleveland Clinic and the Mayo Clinic, who carry out crucial medical evaluations and treatments. Nurses and nurse practitioners of Kaiser Permanente directly engage with the patient daily. The patient is also instructed that information concerning societal factors relating to his health care is handled by social workers and case managers at the American Red Cross.

At CVS Health, pharmacists are primarily responsible for ensuring that the patient’s prescription regimens are both safe and effective. System integration can occur at the local, state, federal, or international levels and may involve public health organizations such as the CDC (Connelly et al., 2021). It also applies to managers and other professionals who are directly involved in patient care planning and decision-making. By becoming members of such organizations and recruiting all the needed experts, the care coordination team is equipped with all the resources needed to respond to patients’ decisions about long-term care and present them with a suitable treatment plan.

Resource Needs for Chronic Care Patients

Slide 8: Hence, one of the critical things in understanding resource requirements is the right approach to operational and capital budgeting needs. Research on business budgeting in the field of healthcare is first described, focusing on the intended objectives and objectives of business budgeting for healthcare organizations, principles, and key approaches to business budgeting in healthcare institutions. Studies evaluate the personal protective equipment required for healthcare workers to identify the gaps and then outline the areas that can assure the safety of the workers during treatment (Dubas, et al., 2023). With an approximate annual amount of $400,000, it proves that some operating needs are medical supplies, protective equipment, doctor’s prescriptions, and many other medical items. Aside from IT professionals, care coordinators, general practitioners, specialists, nurses, social workers, and support personnel are some of the other human resources that will be needed; the cost of implementing them annually is about $1.5 million. By compiling and analyzing different studies, important issues based on the most crucial aspects of the budgeting processes in the sphere of healthcare and specific organizations are identified and discussed in detail in this review. For technology professionals, such money is necessary to support the core IT solutions like EHR solutions or telemedicine; it will be half a million dollars toward this end in the initial stage. Operating and capital expenditures are expected to exceed two million US dollars annually for the year.

Major assumptions include the willingness of participating organizations to share the data, adequate funding from grants and partnerships, and patients and families as active consumers of healthcare services (Batista et al., 2021). One might argue that practitioners may not wish to embrace the need to change and work under the structure that is associated with coordinating treatment from various organizations that may be resourceful and capable differently. The following are these presumptions and uncertainties that are those presumptions i.e., uncertainties. Hence, the objective of the care coordination plan is both an understanding of the total requirements of the long-term care end users as well as developing a well-coordinated system for delivering care.

Project Milestones and Outcome Measures

Slide 9: It is essential to define project goals if a chronic care patient’s care coordination plan is to be effectively implemented. The first is known as the initial formation phase where the formation of all the necessary structures and the building of key alliances is effected in the first three months of the intervention. It means coupling with other significant bodies, which might help in the delivery of care, to identify them, and coordinate suitable support for EHR and sufficient tele-support. The fourth and sixth months of the program comprise the second phase, which is the training and implementation stage. 

At this time some of the staff members should receive training for care coordination and other measures some technological solutions should be introduced (García et al., 2022). The third phase, or the pilot program phase is at months 7-12, during which a small patient group develops trial programs using the care coordination paradigm. It is important, therefore, to identify that the care coordination approach will be used with the rest of the members of the target group in light of the lessons learned during the pilot phase.

 The last stage, which started in the second year and is still ongoing is called the national implementation stage (Capon et al., 2023). There is more than one way to approach connecting service systems for high-demand patient groups, some of which people about how care coordination works for such patients. Another study focuses on listing the principles of patient-centered care and the components of care coordination for persons with chronic diseases. In patients with multiple comorbidities, further research undertook a nurse care coordination scoping assessment for better integration of care delivery.

Outcome Measures

Slide 10: The worth of the care coordination project plus its success is determined by several outcome measures. Some examples of outcome measures include patient satisfaction rating which is obtained from a set of questionnaires to ascertain satisfaction levels of the patient’s relatives (Batista et al., 2021). Research studies have brought into light a care coordination plan that has been adopted in an organization and this has helped enhance the quality of life for patients with chronic diseases. The other is hospital readmission rate which is applied in determining the extent to which care coordination influences the number of times a patient is readmitted back to the hospital.

The need for variations concerning the assessments of patient experience and satisfaction; issues is described in a study aimed at determining the key considerations essential for increasing the quality of healthcare services. Other important health indicators apart from the health status indicators are other health outcomes which will be measured in the diabetic customers including the HbA1c (Capon et al., 2023). These programs of measurement as viewed under the framework of outcomes provide an overall indicator of the project yield and worth, as well as, the degree of fine-tuning required, to ensure that better or enhanced quality of care, could be offered.

Presentation to Administrative Decision Makers

Slide 11: Sometimes the caregivers should communicate when submitting the proposal for care coordination of patients to the administrative decision-making system since the latter may have additional questions about the realization of the plan. Reviewing the information available at the present stage and assessing the impact of EHR integration (Nankya et al., 2022). it can be stated that enhancing the realization of EHR integration leads to the enhancement of safety and the quality of the necessary healthcare in the countries of the industrialized world. Some of the care plan’s major strategies are the vision statement, organization, and incorporation of patient-centered care, identification of projects and resources, and creation of a timetable.

Substantial sources contributing to the above include enhanced organization, communication, identification, and acquisition of necessary resources and orders as well as provisions on measures concerning progress follow-up using usual surveys and indicators (Henein et al., 2022). Some of the questions that one should expect about funding, organization and other agencies’ resistance to change, and inter-organization cooperation. The following questions should be responded to while focusing on the project’s sustainability issues, the roles of involved organizations, and measures of success. Applying practicality and data: Care coordination can be built from scratch by stressing data, and workable solutions from key decision-makers, as well as by including the reigning players of social care and medical care.

Conclusion

Slide 12: The project plan developed for the care coordination for Harmony Health Network contains an effective strategy for handling patients who require chronic care in a manner meant to enhance the overall patient experience. Like previous plans, this plan remembers the multiple needs a patient with long-term care requirements might have. It works together with social workers, other physicians, and community agencies (Mitchell et al., 2024). It also adapts innovative technology used for tracking and communication between all the parties involved. Goals and outcomes that are measurable can only be achieved with well-defined objectives, resources, and goals. It helps to enhance client satisfaction, reduce hospitalization instances, and enhance the utilization of restricted resources. Another perspective is to get the administrative authority to incorporate such an evidence-based, sustainable care model

References

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