Nursing Essay Example - Care Coordination of a Patient

Paper Type: 
Pages:  4
Wordcount:  1002 Words
Date:  2021-03-26

Care coordination of a patient refers to the deliberate organization of the patient care activities and effective sharing of information regarding the patient to the health workers for safer care (Craig, Eby, & Whittington, 2011). Quality healthcare delivery is becoming a burden in the United States due to increasing cost which calls for integrated or coordinated health models for effective care. There is need to come up with a delivery plan of health that has a better outcome at a significantly lower cost. According to Thorpe and Cascio (2013), these strategies have the potential to improve safety and effectiveness of the healthcare system of the US. This paper offers a framework of a Coordinated Care model that improves health interventions and outcomes with efficient access to the system.

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The IHI Care Coordination Model was created by Tom Nolan with the aim of cutting healthcare costs in high-cost populations with multiple social and health needs such as the US (Craig, Eby, &Whittington, 2011). This model has helped me to understand how they can help in reducing triple fail events of poor health experience, outcome, and increased costs. Coordinated follow up leads to effective management of chronic conditions which in effect reduces hospital admissions (Lewis et al., 2013). This is an advantage to the patient as they end up in a better health experience at a significantly lower cost.

Elements of the Model

Personal and Family Assets

The assets refer to the strengths and resources possessed by the people who are in need of healthcare. They include community ties, support groups, family support and the relationship with other providers of social services. They were found to be important in the improvement of ones health according to this model as they are available throughout the entire health process.

Identification of the Patient

The first step is usually to identify those who have been failed by the primary healthcare as they would be the most beneficiaries in this model. It refers to patients who are fond of visiting the emergency departments of hospitals and their illnesses, in most cases, require to be managed inpatient. The identification may also be done by assessing ambulatory-sensitive admissions to find out those who would benefit more from coordinated care (Craig, Eby, &Whittington, 2011).

Care Coordinators

This refers to the care provider who is mandated to identify the health goals of an individual and to coordinate providers and services to achieve this goal. The care coordinator may either be a lay person, community health or social worker, or a nurse care manager depending on the health needs of the patient. This coordinator is required to be an expert in patient advocacy and self-management. They navigate complicated systems and communicate with a huge number of people from the family to physicians and consultants. It is their duty to identify the health goals of the patient and to mobilize and coordinate support from different quarters for a better health outcome. They communicate with the patient professionally to identify their struggles, the assets described above, and their health goals after which they ensure the care plan is carried out effectively. The patients normally work together with them to identify emerging strengths and needs and adjust care plan accordingly.

Barriers to the Implementation of this Model

The implementation and sustainability of this model is likely to face many challenges such as inadequate personnel to work as care coordinators. Most of these patients require individualized attention from professionals which may not be sustainable. Also, the limited use of Electronic Health Records is likely to be a barrier towards the implementation of this model due to loss of information about patients. Although their use is becoming more extensive in many of the hospitals in the United States, the outpatient department has not been covered effectively (Craig, Eby, &Whittington, 2011). Completead option of EHR will require purchase of expensive equipment and further training of the personnel which may bear too high costs. Additionally, Poor engagement between the patients or the family members and the care coordinators due to issues of trust also makes it hard to follow up on the plan of care and outcomes.

Implication of the Model to Nurses

This model has been found to have important implications on both the Community Health Nurses and those working in the hospitals. Nurses will play an important role in the implementation of this model because they are usually the intermediaries between the social care and health sectors. According to Thorpe and Cascio (2013), the model will empower nurses in hospitals to make major decisions regarding the patients whose care they are coordinating. They will be required to adjust the plans accordingly. Additionally, the model will promote safe staffing levels in the hospitals because the model aims to reduce the number of hospital admissions. Overall, the effect will be increased productivity for nurses due to personalized and multidisciplinary care. The model will shift focus of nurses to community health which aims to reduce the frequency of community members visiting the hospital.


The coordinated care model is set to change the American system of health for good. With cooperation between the health cadres involved, the country will see fewer admissions in hospitals and the government will reduce costs of healthcare. The model aims to improve patients health experience, outcome and reduce the amount of money being used in seeking healthcare. It will also transform the Nursing profession as nurses will take part in major decisions regarding the care of their patients.


Craig C, Eby D, &Whittington J. (2011). Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement.

Lewis,G., Kirkham, H., Duncan, I. & Vaithianathan, R. (2013). How Health Systems Could Avert 'Triple Fail' Events that are Harmful, Are Costly, And Result In Poor Patient Satisfaction. Health Affairs, 32 (4), 669-676

Thorpe, J.H. & Cascio, T. (2013). Transforming Healthcare Delivery. Health Reform GPS. GeorgeWashington Universitys Hirsch Health Law and Policy Program: Robert Wood Johnson Foundation. Retrieved from care-delivery/

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