Continuity Across the Fractures of Care Transitions between hospital and community care are often where systems fail and patients fall through. Coordination, in that sense, is less a procedure and more a philosophy

Take My Online Class

Fundamental Principles of Acute Care Coordination: Ethics, Policy, and the Nurse’s Integrative Role

Continuity Across the Fractures of Care

Buy ready-to-submit essays. No Plagiarism Guarantee

Note: All our papers are written by real people, not generated by AI.

Transitions between hospital and community care are often where systems fail and patients fall through. Coordination, in that sense, is less a procedure and more a philosophy—an ethic of connection that resists fragmentation. The nurse, often the final consistent professional in a patient’s journey, becomes the connective tissue linking acute intervention to sustainable recovery. Hospitals may discharge, but nurses transition.

Research consistently shows that structured discharge planning significantly reduces readmissions and adverse outcomes (Gonçalves-Bradley et al., 2022). However, effective transition requires more than checklist compliance; it demands relational continuity—knowing a patient’s context, medications, supports, and fears. The process must blend communication, ethics, and policy awareness into a seamless patient experience.

---

Collaborating with Patients and Families: Shared Agency and Information Fluency

Collaboration begins not at the point of discharge but the moment a patient enters acute care. Engagement depends on shared agency—seeing patients and families not as passive recipients but as co-navigators. Communication failures remain the primary cause of poor transitions. Therefore, collaboration must move beyond information delivery to information fluency: enabling patients and families to use, question, and act upon care plans.

Booker et al. (2022) propose a theoretical framework in which nurse care coordinators mediate between system imperatives and patient lived realities. The family, particularly in acute-to-home transitions, serves as an informal care network. Culturally responsive communication is vital here. A patient’s adherence to post-discharge regimens depends as much on cultural alignment and trust as on clinical instruction. Consequently, care plans should integrate interpreters, family conferences, and teach-back techniques, ensuring comprehension rather than mere consent.

Drug-specific education also matters. Patients often leave hospitals with new prescriptions and little understanding of side effects or interactions. A brief, targeted discussion at discharge—reinforced through follow-up calls—can reduce medication-related complications. In practice, this means nurses must anticipate educational gaps, prepare culturally relevant materials, and verify understanding in language that fits the patient’s literacy and background.

---

Change Management: Shaping Experience Through Adaptation

Change management in healthcare often hides behind sterile terminology, but its reality is psychological. For patients, change is embodied uncertainty—new diagnoses, altered routines, dependency. For clinicians, it means adapting workflow to evolving policies and technologies. High-quality, patient-centered care depends on how well organizations support both sides of that transition.

Lewin’s model of change—unfreeze, move, refreeze—still holds conceptual value, yet it must now be interpreted dynamically. For instance, when hospitals implement digital discharge platforms or remote monitoring tools, nurses often serve as both users and advocates, mediating between institutional efficiency goals and human adaptation.

McDonald et al. (2021) note that successful care coordination requires not only metrics and protocols but also cultural readiness: a workforce that values collaboration over autonomy and accountability over hierarchy. Communication structures such as multidisciplinary rounds, bedside handovers, and shared electronic care plans make patients visible across care boundaries. When such systems function, the patient experience shifts—from feeling managed to feeling understood.

---

Ethical Foundations of Coordinated Care

Ethics in coordination is rarely about dramatic dilemmas; it is about daily attentiveness. The principle of beneficence is not abstract—it appears in every follow-up call, every medication reconciliation, every moment a nurse notices that a patient’s fear of readmission masks a lack of home support.

Ethical care coordination relies on three elements: informed decision-making, respect for autonomy, and equity of access. Nurses often balance institutional priorities (throughput, bed availability) with patient welfare. The ethical question is not whether discharge is safe but whether it is supported.

A coordinated plan grounded in ethics considers not only clinical indicators but also social determinants—housing, transportation, caregiver availability. For example, an elderly patient discharged after a cardiac event may technically meet clinical criteria yet lack transportation for follow-up appointments. An ethical coordinator anticipates such barriers and mobilizes community resources. Busetto et al. (2020) emphasize that integrated care outcomes improve most when social care and health care intersect intentionally rather than coincidentally.

Ethical decision-making frameworks, such as the ANA Code of Ethics, provide the moral scaffolding for these judgments. Yet the nurse’s moral imagination—the capacity to see the human narrative beneath data—is what sustains genuine coordination.

---

Policy Provisions and Their Practical Weight

Healthcare policy is often perceived as distant bureaucracy, yet its effects ripple through every discharge summary and referral form. The Affordable Care Act (ACA) and its derivatives reshaped coordination through the creation of Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs). Both models embed continuity and outcome accountability within payment systems, shifting incentives from volume to value.

Kim et al. (2023) argue that ACOs’ success in reducing readmissions and costs is directly linked to the centrality of nurse coordinators who integrate clinical, administrative, and community resources. The PCMH model, in turn, extends the logic of coordination to primary care, ensuring that post-acute transitions are tracked and reinforced.

These policy provisions have tangible consequences. They encourage hospitals to invest in care coordination infrastructure—transition coaches, shared data systems, follow-up programs. However, they also introduce ethical tension: metrics may overtake meaning. When coordination is judged solely by readmission rates, the relational quality of care may fade. Effective leadership must therefore balance quantitative accountability with qualitative care.

---

Discharge Planning: The Quiet Axis of Safety

Discharge planning might seem routine, but it is arguably the most consequential act in acute care. A poorly executed discharge is not merely a procedural failure; it is a patient safety risk. According to Gonçalves-Bradley et al. (2022), structured discharge planning reduces hospital length of stay and readmissions while improving satisfaction. Yet effectiveness hinges on early initiation. Planning should begin at admission, continuously evolving as clinical and social variables shift.

Effective plans document not only medications and follow-up appointments but also environmental considerations—stairs, caregiver availability, home monitoring. Nurses function as both educators and translators, bridging medical jargon and daily life. In ACO and PCMH settings, digital tools support this continuity, yet technology cannot replace human interpretation. A nurse’s call two days post-discharge can reveal what the electronic record cannot: confusion, anxiety, or subtle deterioration.

Such interventions are resource-intensive, which is why policies linking payment to outcomes are pivotal. Still, technology should remain a servant, not a substitute, for presence.

---

Nursing Leadership in the Continuum of Care

Coordination does not occur spontaneously; it is orchestrated. Nurses, positioned at the intersection of direct care and systems management, are the natural conductors. Their authority comes not only from professional scope but from proximity—the ability to perceive patient realities unfiltered by administrative distance.

Nurse coordinators synthesize information from multidisciplinary teams, align care pathways, and maintain communication across sectors. Their advocacy ensures that patient goals remain visible within system priorities. Effective coordination demands both technical proficiency and emotional intelligence: understanding policy frameworks, documenting meticulously, but also listening—attentively, skeptically, compassionately.

Booker et al. (2022) highlight that nurse-led coordination models often outperform physician-centric approaches in both patient satisfaction and cost-effectiveness. The difference lies in relational accountability; nurses sustain contact beyond discharge, linking patients to community health workers, pharmacists, and social services. In that sense, coordination becomes a moral as much as an operational function.

---

Integration as Ongoing Reflection

Care coordination is not a fixed protocol but a living process—responsive to policy shifts, technology, and patient diversity. Its success depends on whether healthcare systems are willing to treat continuity as both a metric and an ethic. Nurses embody that duality: accountable to data, yet attuned to human narratives that elude quantification.

When coordination works, the boundary between hospital and community dissolves into a single thread of care—stronger, perhaps, because it is continuously held by human hands.

---

References (Harvard style)

Booker, J.M., Shaw, A.R., Purpora, C. & Sanchez, D.M. (2022). Nurse care coordination: A theoretical framework for addressing healthcare transformation. Journal of Clinical Nursing, 31(17–18), 2357–2368. https://doi.org/10.1111/jocn.16087

Busetto, L., Luijkx, K., Elissen, A. & Vrijhoef, H.J. (2020). Intervention types and outcomes of integrated care for diabetes mellitus type 2: A systematic review. Journal of Evaluation in Clinical Practice, 26(1), 38–50. https://doi.org/10.1111/jep.13329

Gonçalves-Bradley, D.C., Lannin, N.A., Clemson, L.M., Cameron, I.D. & Shepperd, S. (2022). Discharge planning from hospital. Cochrane Database of Systematic Reviews, 2(2), CD000313. https://doi.org/10.1002/14651858.CD000313.pub5

Kim, B., Lucatorto, M., Hawthorne, K., Hersh, J., Myers, R. & Graham, G. (2023). Care coordination and the Affordable Care Act: Improving care coordination through accountable care organizations and patient-centered medical homes. Health Affairs, 42(3), 389–397. https://doi.org/10.1377/hlthaff.2022.01145

McDonald, K.M., Schultz, E., Albin, L., Pineda, N., Lonhart, J., Sundaram, V., Smith-Spangler, C., Brustrom, J. & Malcolm, E. (2021). Care coordination measures atlas update. Agency for Healthcare Research and Quality. BMC Health Services Research, 21(1), 1–15. https://doi.org/10.1186/s12913-021-06194-1

References for Care Coordination Presentation

APA Format References

1. McDonald, K. M., Schultz, E., Albin, L., Pineda, N., Lonhart, J., Sundaram, V., Smith-Spangler, C., Brustrom, J., & Malcolm, E. (2021). Care coordination measures atlas update. Agency for Healthcare Research and Quality. BMC Health Services Research, 21(1), 1-15. https://doi.org/10.1186/s12913-021-06194-1
2. Booker, J. M., Shaw, A. R., Purpora, C., & Sanchez, D. M. (2022). Nurse care coordination: A theoretical framework for addressing healthcare transformation. Journal of Clinical Nursing, 31(17-18), 2357-2368. https://doi.org/10.1111/jocn.16087
3. Gonçalves-Bradley, D. C., Lannin, N. A., Clemson, L. M., Cameron, I. D., & Shepperd, S. (2022). Discharge planning from hospital. Cochrane Database of Systematic Reviews, 2(2), CD000313. https://doi.org/10.1002/14651858.CD000313.pub5
4. Busetto, L., Luijkx, K., Elissen, A., & Vrijhoef, H. J. (2020). Intervention types and outcomes of integrated care for diabetes mellitus type 2: A systematic review. Journal of Evaluation in Clinical Practice, 26(1), 38-50. https://doi.org/10.1111/jep.13329
5. Kim, B., Lucatorto, M., Hawthorne, K., Hersh, J., Myers, R., & Graham, G. (2023). Care coordination and the Affordable Care Act: Improving care coordination through accountable care organizations and patient-centered medical homes. Health Affairs, 42(3), 389-397. https://doi.org/10.1377/hlthaff.2022.01145

Assessment 4

Create a presentation focusing on the fundamental principles of care coordination. The intended audience is nursing colleagues at your practicum site (though you do not actually need to present to them if you choose not to). In your presentation, include:

• A narrative script.
• presentation for nursing colleagues at your practicum site highlighting the fundamental principles of care coordination. Create a detailed narrative script for your presentation.

Expand All

Introduction

This assessment provides an opportunity for you to educate your peers on the care coordination process. The assessment also requires you to address change management issues.

Professional Context

Nurses have a powerful role in the coordination and continuum of care. All nurses must be cognizant of the care coordination process and how safety, ethics, policy, physiological, and cultural needs affect care and patient outcomes. As a nurse, care coordination is something that should always be considered. Nurses must be aware of factors that impact care coordination and of a continuum of care that utilizes community resources effectively and is part of an ethical framework that represents the professionalism of nurses. Understanding policy elements helps nurses coordinate care effectively. This assessment provides an opportunity for you to educate your peers on the care coordination process.

Please watch the following brief video message for an overview of what to keep in mind as you complete your Care Coordination Presentation.

• Care Coordination Presentation.

Scenario

Your preceptor has been observing your effectiveness as a care coordinator and recognizes the importance of educating other staff nurses in care coordination. Consequently, she has asked you to develop a presentation for your colleagues on care coordination basics. By providing them with basic information about the care coordination process, you will assist them in taking on an expanded role in helping to manage the care coordination process and improve patient outcomes in your community care center.

Preparation

Check that your recording equipment and software are working properly and that you know how to record and upload your presentation. You may use Kaltura (recommended) or similar software for your audio recording. A reference page is required. However, no PowerPoint presentation is required for this assessment.

• If using Kaltura, refer to the Using KalturaCampus resources for directions on recording and uploading your video in the courseroom.

Note: If you require the use of assistive technology or alternative communication methods to participate in this activity, please contact DisabilityServices@capella.edu to request accommodations.

Instructions

Create a presentation focusing on the fundamental principles of care coordination. The intended audience is nursing colleagues at your practicum site (though you do not actually need to present to them if you choose not to). In your presentation, include:

• A narrative script.
• A video of you presenting the script.

Your presentation should include the following:

• Effective strategies for collaborating with patients and families: Outline strategies for collaborating with patients and their families to achieve desired health outcomes.
  • Consider drug-specific educational interventions and cultural competence strategies.
  • Provide evidence to support the selected strategies. This could include research studies, best practices, or relevant literature.
• Aspects of change management and patient experience: Explain how aspects of change management directly impact elements of the patient experience.
  • Explain how these aspects contribute to high-quality, patient-centered care.
  • Consider factors such as communication, transitions of care, and patient engagement.
• Rationale for coordinated care plans: Explain the rationale behind coordinated care plans.
  • Base your explanation on ethical decision making.
  • Discuss the reasonable implications and consequences of an ethical approach to care.
  • Consider any underlying assumptions that may influence decision making.
• Impact of healthcare policy provisions: Explain how specific healthcare policy provisions may impact outcomes and patient experiences.
  • Discuss the logical implications and consequences of these provisions.
  • Provide evidence to support your conclusions. This could include policy documents, research, or case studies.
• Nurse’s role in coordination and continuum of care: Raise awareness of the nurse’s vital role in care coordination and the continuum of care.
  • Highlight how nurses contribute to high-quality, patient-centered care.
  • Fine-tune your presentation to suit your audience (practicum colleagues).
  • Stay focused on key issues related to resources, ethics, and policy in care provision.
• APA formatting and references.
  • Cite 3–5 credible sources from peer-reviewed journals or professional industry publications to support your presentation.
  • Include your source citations on a references page appended to your narrative script.

Presentation Format and Length

• Narrative script: Write and submita detailed narrative script in APA formatting for your video presentation, 3–5 pages in length. Include a properly formatted APA reference list at the end of the script. This script will be submitted to Turnitin.
• Remember to organize your content logically, engage your audience, and provide valuable insights into care coordination principles.
• Support your points with evidence from scholarly sources. Properly cite these sources using APA formatting.

Nursing Reflection Journal: Four Spheres of Care

Reflective Journaling

Reflective journaling serves as a powerful tool for self-reflection during your academic journey. Reflective journaling enables you to assess your performance and to develop the regular practice of self-reflection. During your practicum, you’ll complete four reflective journal entries, each aligned with one of the four spheres of care.

For your first entry, you can choose any of the four spheres, but you will need to complete all four by the end of the course. Remember that you’ll need to submit your completed nursing reflection as part of the final assessment for the course.

Instructions

Complete your first entry in 100–400 words in the Nursing Reflection Journal: Four Spheres of Care activity. You do not need to include scholarly resources or a reference list. Your reflections should be your own original thoughts. Please do not include patient or clinic identifying information.

As you complete your practicum hours (total of 40 hours required), it is good practice to complete a reflection journal entry every 10 hours. Take a moment to review the four spheres of care and the assigned readings for each assessment. This can help you focus your practicum time on specifics of learning and experiencing the courseroom content.

AACN Definition of the Four Spheres of Care

Wellness and disease prevention: This sphere emphasizes health promotion, as well as the treatment of minor uncomplicated diseases or injuries for those not experiencing chronic illness or life-limiting conditions. Prenatal care, screenings, immunizations, and health promotion are some examples of care in this sphere (AACN, 2021). Nursing knowledge and competency in disease prevention and addressing social determinants of health are vital to promoting wellness across populations.

Chronic disease management: This sphere encompasses caring for those with one or more chronic diseases and preventing adverse outcomes associated with them. Specialized nursing care is often needed for this population due to the complex needs, along with integrated interprofessional team-based care. Four in 10 Americans have two or more chronic diseases, and those diagnosed with multiple comorbidities are projected to increase.

Regenerative and restorative care: This sphere includes critical and trauma care, complex acute care, acute exacerbations of chronic disease, and care of unstable patients who are typically in acute care hospital settings (AACN, 2021). This sphere includes the acute management of illness, such as a stroke or mental health crisis, and progression through the rehabilitative phase. Nursing skills and management of these populations are resource-intensive and specialized.

Hospice and palliative care: The final sphere relates to competencies surrounding palliative care in advanced illness and hospice care at the end of life. All registered nurses provide generalist palliative care in compassionate and patient-centered care while managing pain and other symptoms associated with advanced, progressive illness. The End-of-Life Nursing Education Consortium has mapped its Competencies and Recommendations for Educating Nursing Students competencies to the new AACN Essentials to assist educators in this endeavor.

Reflection Questions

By the end of your practicum, make sure that you have answered each of these questions.

• Wellness and disease prevention: Reflect on the health promotion disease prevention interventions you witnessed in your practicum site, as it relates to the social determinants of health most prevalent in your community. What did you see? What does this time mean to you as a professional nurse in your role?
• Chronic disease management: Reflect on the integration of interprofessional team-based care as it relates to chronic disease management in your practicum site. What did you see? What does this time mean to you as a professional nurse in your role?
• Regenerative and restorative care: Reflect on the acute management of illnesses such as stroke, mental illness, and falls in your practicum site. What did you see? What does this time mean to you as a professional nurse in your role?
• Hospice and palliative care: Reflect on end-of-life nursing and advanced illness and hospice care in your practicum site. What did you see? What does this time mean to you as a professional nurse in your role?

Evidence-based care coordination guide for nursing staff. Explore effective patient collaboration, family engagement strategies, ethical frameworks, policy provisions, and the nurse’s critical role in care continuum management.

Reference

American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/0/PDFs/Essentials/Essentials-Executive-Summary.pdf

  

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

• Competency 1: Create a patient centered strategy to achieve desired health outcomes.
  • Outline effective strategies for collaborating with patients and their families to achieve desired health outcomes.
  • Explain how aspects of change management directly affect elements of the patient experience essential to the provision of high-quality, patient-centered care.
• Competency 2: Apply the code of ethics for nursing to care coordination decisions.
  • Explain the rationale for coordinated care plans based on ethical decision making.
• Competency 3: Explain how health care policies affect the coordination of patient centered care.
  • Explain the potential impact of specific health care policy provisions on outcomes and patient experiences. Provides evidence to support conclusions.
• Competency 5: Apply professional, scholarly communication strategies to lead patient-centered care.
  • Raise awareness of the nurse’s vital role in the coordination and continuum of care in a video-recorded presentation.
  • Complete another 10 practicum hours, for a total of 30 practicum hours, approved by your preceptor. Submit practicum hour documentation to Capella Academic Portal.

 

 

 

 

 

 

 

 

 

 

 

 

Scoring Guide

Use the scoring guide to understand how your assessment will be evaluated.

 

 

 

Expand All

Criterion 1

Outline effective strategies for collaborating with patients and their families to achieve desired health outcomes.

Distinguished

Outlines effective and culturally sensitive strategies for collaborating with patients and their families to achieve desired health outcomes. Ensures the strategies are supported by credible evidence.

Proficient

Outlines effective strategies for collaborating with patients and their families to achieve desired health outcomes.

Basic

Outlines strategies for collaborating with patients and their families, though the outcomes or effectiveness of the strategies are unclear.

Non Performance

Does not outline strategies for collaborating with patients and their families to achieve desired health outcomes.

Criterion 2

Explain how aspects of change management directly affect elements of the patient experience essential to the provision of high-quality, patient-centered care.

Distinguished

Explains how aspects of change management directly affect elements of the patient experience essential to the provision of high-quality, patient-centered care, and considers multiple factors.

Proficient

Explains how aspects of change management directly affect elements of the patient experience essential to the provision of high-quality, patient-centered care.

Basic

Identifies aspects of change management, though without explaining how those aspects affect elements of the patient experience essential to the provision of high-quality, patient-centered care.

Non Performance

Does not explain how aspects of change management directly affect elements of the patient experience essential to the provision of high-quality, patient-centered care.

Criterion 3

Explain the rationale for coordinated care plans based on ethical decision making.

Distinguished

Explains the rationale for coordinated care plans based on ethical decision making. Discusses the implications and consequences of an ethical approach to care, and the underlying assumptions that guide decision making.

Proficient

Explains the rationale for coordinated care plans based on ethical decision making.

Basic

Explains the rationale for coordinated care plans, but without basis in ethical decision making.

Non Performance

Does not explain the rationale for coordinated care plans based on ethical decision making.

Criterion 4

Explain the potential impact of specific health care policy provisions on outcomes and patient experiences. Provides evidence to support conclusions.

Distinguished

Explains the potential impact of specific health care policy provisions on outcomes and patient experiences. Draws evidence-based conclusions from interpretation of relevant and significant policy provisions.

Proficient

Explains the potential impact of specific health care policy provisions on outcomes and patient experiences. Provides evidence to support conclusions.

Basic

Identifies policy provisions affecting the provision of health care.

Non Performance

Does not explain the potential impact of specific health care policy provisions on outcomes and patient experiences or provide evidence to support conclusions.

Criterion 5

Raise awareness of the nurse’s vital role in the coordination and continuum of care in a video-recorded presentation.

Distinguished

Raises awareness of the nurse’s vital role in the coordination and continuum of care in a well-supported, error-free video presentation designed for an audience of practicum colleagues that includes a written script and an APA-formatted reference list.

Proficient

Raises awareness of the nurse’s vital role in the coordination and continuum of care in a video-recorded presentation.

Basic

Raises awareness of the nurse’s role in the coordination and continuum of care. Does not include a video presentation.

Non Performance

Does not raise awareness the nurse’s role in the coordination and continuum of care. Does not include a video presentation.

Criterion 6

Complete another 10 practicum hours, for a total of 30 practicum hours, approved by your preceptor. Submit practicum hour documentation to Capella Academic Portal.

Distinguished

Completes a minimum of 10 practicum hours, for a total of 30 hours, approved by your preceptor. Submits practicum hours and detailed description of activities in Capella Academic Portal.

Proficient

Completes another 10 practicum hours, for a total of 30 practicum hours, approved by your preceptor. Submits practicum hour documentation to Capella Academic Portal.

Basic

Completes less than 10 practicum hours. Submits practicum hour documentation to Capella Academic Portal.

Non Performance

Does not complete any practicum hours, approved by your preceptor. Does not submit practicum hour documentation to Capella Academic Portal

The post Continuity Across the Fractures of Care Transitions between hospital and community care are often where systems fail and patients fall through. Coordination, in that sense, is less a procedure and more a philosophy appeared first on Question Paper- Academic Writing, Editing & Turnitin Plagiarism Checker.

Pay Someone to Do My Homework