Care Coordination Basics
What is care coordination?
The deliberate organization of patient care involving at least one other participant.
What is one attribute of integrated care?
Interprofessional communication.
What is one role nurses have during transitions?
Supporting the patient through the change (e.g., discharge, transfer).
Name one community partner involved in care coordination.
GP, pharmacist, home care, rec programs, specialists.
What conversation supports alignment of care with patient values?
Goals of Care discussions.
Why is care coordination important?
It improves safety, quality, efficiency, and outcomes.
What does proactive planning involve?
Anticipating needs and arranging follow-up care.
Why is thorough assessment critical for coordination?
It captures full patient needs to guide the plan.
Why must nurses know available resources?
To ensure timely, appropriate referrals.
What does open communication about prognosis help with?
Preparing the patient and guiding decision-making.
What does an individualized care plan need to be?
Patient-centered and evidence informed.
What does "value-based care delivery" mean?
Care that maximizes outcomes while being cost-effective.
What does advocacy in care coordination mean?
Speaking up to ensure the patient receives needed resources/services.
What social determinant often impacts coordination success?
Transportation, income, or housing.
Why is family support essential in integrated palliative care?
They are part of the care unit and need guidance through illness changes.
What does effective care coordination require across teams?
Consistent communication and information sharing.
What is required for successful team-based care?
Collaboration and respect for each other's roles.
What is the nurse's role in interprofessional teamwork?
Communicating clearly and helping unify the plan of care.
What does "appropriate resource allocation" refer to?
Mobilizing the right services at the right time.
What ensures seamless care as settings change (home -> hospital -> hospice)?
Consistent communication and continuity of the care plan.
What must providers look beyond to coordinate well?
Their own clinical setting - consider community, home, and system-level supports.
What three categories does integrated care address?
Social, behavioural, and medical needs.
What palliative principle must nurses uphold across settings?
Consistent, seamless care that aligns with goals of care.
Why is communication with community providers essential?
To avoid gaps, duplication, or conflicting plans.
When should specialized palliative care be consulted?
When needs become complex or exceed generalist capacity.