Historically, advanced registered practice nurses (APRNs) have worked collaboratively with other healthcare providers to offer care coordination and care management. Evidence shows that when APRNs such as Nurse Practitioners (NPs) are tasked with managing interdisciplinary teams, best patient outcomes are achieved at lower costs. This is because APRNs are capable of providing the horizontal leadership required to coordinate and manage care to help improve the availability of primary care and meet the needs of patients. As a result, it has been projected that in the near future, NPs will constitute the leading providers of care coordination in diverse healthcare settings. In addition, the existing technology, financial, and legislative circumstances have helped to expand the leadership role of NPs with respect to care coordination now as well as the in the future. For instance, the Affordable Care Act offers policy support for NPs to integrate care coordination practices. Against this backdrop, this paper shows the positive effect of care coordination by NPs on patient care in home health settings.
Ways in Which an NP can Implement Care Coordination in Home Health Setting
The home health setting is one of the care settings where NPs can implement care coordination. The effectiveness of the home health model is considerably dependent on the extent to which care is coordinated since care is offered in out-of-hospital settings. The care coordination activities that can be undertaken by NPs include assessing, planning, implementing, and evaluation. These activities require the NP to play the role of the care coordinator in charge of organizing care coordination together with the involvement of other team members in the care team such as the other healthcare providers, family members, and the patient. The care coordination process in the home health setting requires the active engagement of the patient and his/her family members via continued encouragement, self-management, and direction.
NPs in home health settings must undertake comprehensive assessment with the aim of understanding the health needs of the patient, the goals and objectives of care, and the resources that are available to the patient. In home health settings, the assessment is conducted on a face-to-face basis with data gathered relating to various domains such as the use of health services, resources, social support, functional, environmental, financial, spiritual, development, cultural, lifestyle, cognitive, social, and physical domains. Standard instruments are used to conduct the assessment and understand the preferences and values of patients regarding care. From the comprehensive assessment, NPs can document the perspectives of patients regarding their fears, challenges they face when managing their condition, and care goals. The insights gained from comprehensive assessment can be used to develop the care plan including the shared care goals of the NP and the patient.
The second activity is care planning, which comprises of collaborative activities that are geared towards developing the care plan with the involvement of the healthcare team, patient, and his/her family members. During care planning, NPs should allow patients to participate by determining their care goals, after which the NP should help them in personalizing and prioritizing the treatment recommendations. In the care planning process, the NP developed a care plan is comprehensive and based on evidence to ensure that the needs of the patient are considered including his/her preferences, requirements, and values.
The implementation phase of care coordination in home health entail the identification of barriers that exist to the realization of the care plan. The patient together with the care team should engage in problem solving aimed at mitigating the barriers. The activities that the NP as the care coordinator and manager in home health settings including teaching patients on the disease processes, self-management approaches, and medications; health coaching aimed at reinforcing the positive steps undertaken by the patient; and referring the patient to receive appropriate community support and services. Importantly, the coordination activities entail coordinating community and health services, synchronizing communication among those involved in providing patient care such as the specialist physician; community based agencies like faith-based organizations and exercise programs; mental health practitioners; rehabilitation specialists; and emergency and hospital staff. Lastly, the NP should evaluate the coordination effort proactively and document the progress of the patient towards the realization of treatment goals such as visits to the emergency department. The care plan and goals should be revised accordingly based on the outcomes of the evaluation.
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Influence of Information Technology and Electronic Health Records on Care Coordination
With the advancement of medical technologies and practices, healthcare providers are expected to deliver high quality healthcare services. Before the advent of health information technologies (HITs) such as electronic health records (EHRs), the interactions between providers and patients was limited and specific and was dependent on the providers expertise and perspective of the patient. As a result, view of the patient from the perspective of providers was fragmented. With the advent of HITs and EHRs, integration between providers has increased due to the better sharing of information. By leveraging EHR, practitioners are capable of viewing updated allergy and medication lists. In addition, the standardized data, care plans, and order sets contained in EHRs facilitate the implementation of common treatment for patients based on evidence-based approaches. EHRs also facilitate a disease management that is simpler, faster, and convenient. Taken together, HITs contribute to better care coordination through information sharing.
EHRs also enhance care coordination through minimizing the fragmentation of care. This is because EHRs are capable of integrating and organizing health information of patients and enabling the distribution of information between providers in the patient care team. For instance, EHRs can alert providers when their patient has been admitted; thus, prompting proactive action. EHRs also offers providers with updated and accurate information regarding the patient, which is particular essential in a care coordination context whereby a patient is visiting many care specialists, transitioning between various care settings, being treated in emergency care settings, and ensuring that the patient information is readily available to mitigate medical errors and unwarranted tests. The availability of patient information also lessen the probability that the one care specialist will not be informed of an unrelated although relevant condition that another specialist is managing. Therefore, EHRs contribute to care coordination by minimizing the fragmentation of care.
Facilitating Factors and Barriers and Challenges Related to Care Coordination Practices
The facilitating factors and barriers to care coordination occur at three levels including system/organizational, interpersonal, and individual factors. At the system level, the availability of onsite resources for patients is a key facilitator of care coordination. The ability to access resources from a single site enables integration of care. At the interpersonal level, care coordination is facilitated by good working relationships between care providers. Good working relationships enable the sharing of information as well as integrated practice. Another facilitating factor for care coordination is the adoption of HITs. These technologies facilitate care coordination by lessening the fragmentation of the healthcare system as well as by integrating and organizing health information of patients and enabling the distribution of information between providers in the patient care team.
At the system/organizational level, caseload burden is one of the challenges to effective care coordination. As Friedman et al. explains, dealing time consuming patients including those with mental illness, terminal diseases and those having problems with health coverage hinder the ability to coordinate care effectively. Moreover, having more patients to manage and follow up poses a considerable challenge for care coordinators. Friedman et al. reports that the majority of care coordinators managed at least 300 patients in their caseload, which is demanding and challenging. In addition, competing aspects of NPs roles of case management and data management hinder effective care coordination. Many NPs acting as care coordinators have to track and enter quality metrics into EHRs while at the same time helping patients in managing their conditions, which leads to frustrations and pressures. Another barrier to effective care coordination at the organizational level include the use of HITs lacking the necessary functionalities. Most EHRs cannot run reports on particular patient populations. In addition, the limited availability of community resources for patients is a barrier to care coordination. At the interpersonal level, the offsite location of the care coordination team is a barrier to care coordination since lack of face-to-face contact hinders the ability of care team members to communicate effectively and build relationships, which sometimes lead to miscommunication and slow workflow. Another barrier impeding effective care coordination related to lack of trust from patients and their inability to self-manage their conditions. Many patients prefer to be treated in hospital settings despite having a case manager.
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How NP Advocacy Influence Legislative Practices
NP advocacy at the local, state, and national levels have a significant influence on legislative practices. When NPs adopt the advocacy role to reform the health care system, they focus on championing for the adoption of laws to enhance patient care and the adequate allocation of resources towards the same. Various ways exist through NPs can engage in advocacy work including the initiation of policy proposals, vetoing or amending policy proposals suggested by others, and influencing how health policy is implemented. Contemporary NPs often engage in advocacy aimed at bringing about changes in the existing laws, regulations and policies governing the wider healthcare system. Several specialty nursing and state nursing organizations perform policy workshops, provide policy internships, and sponsor legislative days, which all seek to provide NPs with the chance to get acquitted with contemporary issues in healthcare as well as the legislative process. By participating in professional organizations, novice advocates interact with experienced advocates to act as their mentors, from which they can build their legislative experience. The specific approaches in which NPs can influence legislative issues include getting elected to a public office, writing a letter to those with legislative authority, testifying on issues or problems during public meetings and defending the proposed solutions, lobbying decision-makers, and working with the media to highlight a problem including the proposed solutions. By engaging in these advocacy efforts, NPs can influence policy.
Effective advocacy can bring about major changes with respect to the healthcare systems. In California, the effect of NP advocacy are evident, especially with respect to expanding the practice scope for NPs. For instance, NPs successfully advocated to expand their practice scope to be able to request, receive, and dispense pharmaceutical samples. Currently, professional organizations such as the California Association for Nurse Practitioners are engaged in lobbying efforts to expand the practice scope for NPs.
Care coordination by NPs can have significant positive effects on patient care in home health settings. NPs can implement care coordination through include assessing, planning, implementing, and evaluation together with the involvement of other team members in the care team such as the other healthcare providers, family members, and the patient. By leveraging HITs, care coordination can be enhanced through information sharing and minimizing the fragmentation of care. The factors facilitating care coordination include accessibility to resources at a single site/facility; good inter-disciplinary relationships; and adoption of HITs. The barriers to effective care coordination include caseload burden; competing aspects of NPs roles of case management and data management; HITs lacking the necessary functionalities; offsite location of the care coordination team; and lack of trust from patients and their inability to self-manage their conditions.