NURS FPX 6618 Assessment 1

NURS FPX 6618 Assessment 1 Planning and Presenting Care Coordination Plan


Capella University


Instructor’s Name

March 2024

NURS FPX 6618 Assessment 1

Assessment 1: Planning and Presenting Care Coordination Plan

Slide 1: Hello, I am pleased to submit a thorough care coordination project plan to meet our community’s complicated chronic care needs. 

Slide 2: We must aggressively address chronic disease concerns as we change healthcare delivery. This presentation describes a strategy for organizing and consolidating care across various organizations, leveraging interagency collaboration, and using innovation to improve chronic care patients’ quality of life and health outcomes. We seek to redefine care coordination by streamlining processes to improve the well-being of patients. 

Vision for Interagency

Slide 3: This vision encompasses a multifaceted approach, where primary care serves as the cornerstone of coordination, supported by a network of specialists, allied health professionals, and community resources. Through the adoption of interoperable electronic health records (EHR) systems and standardized care protocols, information sharing and care transitions become smooth, ensuring continuity of care across various healthcare settings (Pascucci et al., 2020). Furthermore, patient engagement and empowerment are prioritized, with active involvement in care planning and decision-making processes to promote self-management and improve health outcomes.

Slide 4: To achieve this vision, underlying assumptions include the willingness of healthcare organizations to collaborate effectively and share resources for the collective benefit of chronic care patients. Additionally, assumptions are made regarding the availability of technological infrastructure and support for implementing EHR systems and interoperability standards. However, areas of uncertainty may arise regarding the sustainability of funding for care coordination initiatives, the scalability of the proposed model across diverse healthcare settings, and potential challenges in aligning organizational cultures and workflows to facilitate seamless collaboration. 

Identifying the Organizations

Slide 5: In caring for chronic care patients, a multitude of organizations and groups must collaborate to provide comprehensive and effective care. Primary among these are primary care clinics, such as community health centers, family medicine practices, and internal medicine clinics, which serve as the initial point of contact and ongoing management for chronic conditions (Tomaschek et al., 2022). Specialists, including cardiologists, endocrinologists, pulmonologists, and neurologists, play a crucial role in managing specific aspects of chronic diseases. Hospitals, including academic medical centers and community hospitals, are essential for acute exacerbations, surgeries, and specialized interventions (Tomaschek et al., 2022). Rehabilitation centers, such as physical therapy clinics and inpatient rehabilitation facilities, offer support for physical and occupational therapy to enhance patients’ functional abilities. Home health agencies, including visiting nurse associations and home care agencies, provide services such as skilled nursing, wound care, and assistance. 

Slide 6: Moreover, social service agencies, such as the Department of Social Services, United Way, and local non-profit organizations, are vitals. Patient advocacy groups, such as the American Heart Association, American Diabetes Association, and Alzheimer’s Association, play a crucial role in empowering patients, providing education, and advocating for their rights and needs within the healthcare system. Pharmacies and pharmacists, including retail pharmacies, hospital pharmacies, and specialty pharmacies, are integral in medication management, ensuring adherence, monitoring for drug interactions, and providing education about medications (Bonnell et al., 2021). Finally, caregivers, including family members and informal caregivers, are essential members of the care team, providing support, assistance, and continuity of care outside of formal healthcare settings.

Determining the Resource

Slide 7: To determine the resource needs of chronic care patients, a comprehensive and detailed accounting of various resources is essential. This includes medical supplies such as medications, durable medical equipment, wound care supplies, and monitoring devices. Additionally, staffing requirements are crucial, encompassing primary care physicians, specialist physicians, nurses, nurse practitioners, physician assistants and pharmacists (Chang et al., 2022). Capital needs may involve investments in healthcare facilities, equipment upgrades, and technology infrastructure, including electronic health record systems and telemedicine platforms. Moreover, financial resources are necessary to cover the costs associated with medical services, medications, transportation assistance, home modifications, caregiver support services, and patient education programs. Community resources also play an important role in meeting the holistic needs of chronic care patients (Chang et al., 2022). Assumptions underlying these resource needs include stable funding sources, availability of skilled healthcare professionals, accessibility of healthcare facilities and services, and patient engagement in care management. However, uncertainties may arise regarding fluctuations in healthcare funding, workforce shortages, technological challenges, and evolving patient needs and preferences. Despite these uncertainties, logical inferences based on relevant information suggest that adequate resource allocation, strategic planning, and continuous evaluation are essential to meet the diverse and evolving needs of chronic care patients effectively.

Project Milestones

Slide 8: Identifying project milestones and outcome measures requires keen insight into the full scope of the care coordination project for chronic care patients and the expected outcomes. Milestones should be strategically chosen to mark significant progress points throughout the project timeline. These may include electronic health record systems to facilitate information sharing, standardized care protocols across participating organizations, comprehensive patient assessments to identify needs and preferences, individualized care plans tailored to each patient’s unique circumstances, medication management and lifestyle modifications, and monitoring and (Liu & Kauffman, 2020). Each milestone should ensure clarity and accountability throughout the project.

Slide 9: Similarly, outcome measures should align with the overarching goals of the care coordination project and reflect meaningful improvements in patient health outcomes, quality of care, and cost-effectiveness. These may include reducing hospital readmissions and emergency department visits, improving disease management indicators such as blood pressure and blood glucose control, enhancing patient satisfaction and engagement in care, increasing adherence to treatment plans and medication regimens, and achieving cost savings through more efficient resource utilization and reduced healthcare utilization (Duan et al., 2021). Outcome measures should be evidence-based, reliable, and sensitive to changes resulting from care coordination efforts, allowing for continuous monitoring and adjustment of interventions to optimize outcomes for chronic care patients. By carefully selecting project milestones and outcome measures, healthcare providers can effectively track progress, evaluate the impact of care coordination interventions, and drive improvements in the delivery of care for chronic care patients.


Slide 10: The care coordination project plan presented today represents a bold step forward in our commitment to delivering high-quality, patient-centered care for chronic care patients. By fostering collaboration among diverse organizations, leveraging innovative technologies, and prioritizing the holistic needs of our patients, we have laid the foundation for a more integrated and effective healthcare system. As we move forward, let us remain steadfast in our dedication to continuous improvement, ensuring that every decision we make is guided by the principles of compassion, equity, and excellence. 


Bonnell, L. N., Crocker, A. M., Kemp, K., & Littenberg, B. (2021). The relationship between social determinants of health and functional capacity in adult primary care patients with multiple chronic conditions. The Journal of the American Board of Family Medicine, 34(4), 688–697. https://doi.org/10.3122/jabfm.2021.04.210010 

Chang, E., Ali, R., Seibert, J., & Berkman, N. D. (2022). Interventions to improve outcomes for high-need, high-cost patients: A systematic review and meta-analysis. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-022-07809-6 

Duan, W., Ullman, K., Majeski, B., Miake, I., Diem, S., & Wilt, T. J. (2021). Care coordination models and tools—systematic review and key informant interviews. Journal of General Internal Medicine, 37(6), 1367–1379. https://doi.org/10.1007/s11606-021-07158-w 

Liu, N., & Kauffman, R. J. (2020). Enhancing healthcare professional and caregiving staff informedness with data analytics for chronic disease management. Information & Management, 103315. https://doi.org/10.1016/j.im.2020.103315 

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 

Tomaschek, R., Lampart, P., Scheel, A., Gemperli, A., Merlo, C., & Essig, S. (2022). Improvement strategies for the challenging collaboration of general practitioners and specialists for patients with complex chronic conditions: a scoping review. International Journal of Integrated Care, 22(3), 4. https://doi.org/10.5334/ijic.5970

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