NURS FPX 6618 Assessment 1 Planning and Presenting a Care Coordination Project

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Planning and Presenting a Care Coordination Project

Today, there is a wide scope and development of the role of professional nursing due to healthcare complexities that have increased, thus forcing us to continue changing to fit the present society’s needs (Smith et al., 2020). NURS FPX 6618 Assessment 1 enhance co-ordination while delivering care services to patients who need multi-agency care interventions is one of the biggest issues but, at the same time, one of the biggest opportunities for us to use all our knowledge, tools, and contacts in order to change the lives of people that we are working with.

The vision of Interagency Coordinated Care for a Population

Coordinated care for elderly adults from multiple agencies as a model of enhancing the continuity of care to effectively meet the needs of the senior citizens is well encapsulated in our vision for the interagency coordinated care of elderly adults in the future society (Smith et al., 2020). Embedded in all of this is the understanding that older adults need a range of services that can be categorized into sectors of health, social welfare, education and community. NURS FPX 6618 Assessment 1 attains this vision, a center that centralizes all information gathering, dissemination, and decision-making regarding the care coordination process is needed. This hub will connect healthcare providers, other stars, social workers, case managers, and caregivers and formulate an individual-centered plan to meet the needs of each stakeholder.

NURS FPX 6618 Assessment 1 Organizing and Consolidating Care

Centralized Care Coordination Hub: The creation of a directory that contains all information concerning elderly adults and which information should be available to permit making necessary decisions by those with the authority to do so. Since this will be an online hub of care plans, health-status assessments, daily progress notes, and other relevant information, they will also be able to synchronously coordinate and make decisions.

Interprofessional Care Teams: Health care providers, including nurses, physicians, social workers, informal caregivers, and other community stakeholders, will organize into interprofessional practice teams to establish and execute individual elders’ plans of care. These teams will convene regularly to discuss progress, make changes to interventions, and problem-solve barriers. These teams will meet as often as necessary to fully evaluate progress, change the types of interventions provided, and address any barriers to care.

NURS FPX 6618 Assessment 1 Standardized Protocols and Workflows: Coordinate admission, discharge, and other transitional care processes by operating from standard protocols and processes in organizations involved for organizational congruity and review of elderly adults (Jones & Johnson, 2019). This may include establishing generic care models, clinical information exchange, models for shared care, etc., to standardize the functioning framework.

Organisations and Groups Who Must Participate in Caring for a Population

There are a few important aspects to be pointed out aimed at the proper delivery of care for the elderly population: a complex of teams’ work, multi-professional cooperation and mutual support of organisations and groups which can help elderly people. These include:

Healthcare Providers: The role of a number of professionals, including primary care physicians, specialists, nurses and allied health professionals, in diagnosing, treating and managing medical conditions affecting the elderly population cannot be ignored (Johnston et al. , 2020). Home Healthcare Agencies: Administer professional oversight, nursing, physical and occupational therapy, medical treatment, and support with basic physical personal needs for seniors who need home care (Miller & Weissert, 2019). Hospice and Palliative Care Organizations: Ensure hospice or terminal care and aid for elderly people who have chronic diseases or terminal illnesses(NURS FPX 6618 Assessment 1).

Social Services Agencies: The Area Agencies on Aging (AAA) is an organisation that offers care for elderly clients in particular regions with the services offered being comprehensive and may include the following: Case management services, transportation services, meal services, and caregiver programs (Lendon et al., 2020). Social Work Agencies: In the following section, social workers’ responsibilities, processes and goals are explained in detail regarding the assessment of the elderly person’s needs, facilitating access to community resources and the means of advocating for them (Drennan & Larkin, 2019).

Community Organizations: Senior centres: This is a places where elderly people can go to interact with others, engage in physical activities, learn new things or even receive other assistance and support. Faith-Based Organizations: Religion often created social structures and ways in which religious organizations such as churches, synagogues, mosques, and other similar institutions may offer elderly support, services, and volunteerism within the elderly congregation member population (Hatch & Hammoudeh, 2020).

Insightful and Comprehensive Analysis of the Environment and Provider Capabilities:

In analysing the environment and provider capabilities for caring for the elderly population, several factors must be considered:

Demographic Trends: Demographics: Longevity is still rising, with people living much longer into older ages democratically, and this new population characteristic poses both a chance and a threat to health care and social service organizations (Ortman et al., 2019). Geographic Distribution: The level and distribution of services that elderly persons may be able to access can be influenced by factors such as population density, the extent of urbanisation, and geographic access (Salinas & Al Snih, 2020).

Healthcare Infrastructure: There may be a scarcity of health facilities such as hospitals or clinics and specialty care services, and to get access to healthcare for elderly communities in those areas, there may be a need for unique solutions that will help to address the issue (Cudjoe et al., 2019). Telehealth and Remote Monitoring: Telemedicine techniques and home monitoring can help elderly people receive practical care with limited COVID-19 risks and can be useful for the elderly living in rural areas or with limited access to healthcare (Maresca et al., 2021)

Provider Capacities: The spectrum of human resources in the healthcare industry, including physicians, nurses, and all other related workers such as allied health professionals, may have a shortage of supply in some specialty areas or limited areas of geography, which can result in inefficiency in providing adequate care for the elderly population (Kash et al . , 2020). Interprofessional Collaboration: Telemedicine and remote care delivery integrated with the collaborative care models of the multidisciplinary team, which includes doctors, nurses, social workers, and community-based advocates, can interrelate and provide quality care services effectively to elderly patients by increasing geriatric care access and decreasing the barrier to geriatric health equity (Chan et al., 2021).

NURS FPX 6618 Assessment 1 Resource Needs of a Population

Determining the resource requirements needed for the elderly group requires evaluation of the physical and non-physical assets of important to cater for this group of people. Major tangible assets include funding required for the provision of healthcare services, social support services to cash-strapped families, support services for the carers and development of facilities and structures (Aldridge et al. , 2021). These funds may be received in several forms, such as government grant aids, private donations, healthcare cost reimbursement, and philanthropic sponsorships.

However, it is imperative to note some challenges and instabilities pertaining to funding the programs due to fluctuations in economic conditions and healthcare policies or legislation. Another important area of concern is people or human capital, which includes not only the healthcare junta, social workers, caregivers, and volunteers but also the administrative staff. Possible limitations can be a short supply of healthcare employees or potential employees in some specialties or regions, which may provoke difficulties in providing an adequate and full spectrum of care (Jones & Johnson, 2019). Also, infrastructure constraints for some patients and families, burden and stress of family caregivers are also listed though they are very valuable and essential to get help and prevent the burnout situation for family caregivers.

Making Logically Sound Inferences

Based on the information gathered and analysis made, if he obtains some logical conclusions, he will easily deduce that taking care of an elderly person is not just a one-dimensional process; it requires enhancing the efforts as well as the cooperation of another department. The importance of investment cannot be overemphasised and this includes investing in healthcare workforce production as well as enhancing health infrastructure, encouraging technological advancement and providing support for social programs. NURS FPX 6618 Assessment 1 utilisation of varying resources and collaborations may help address resource deficiencies and minimize the vulnerability of elderly patients as well as enhance the efficiency of distribution of available resources that would finally create better opportunities for efficient delivery of tailored and comprehensive care for elderly patients.

Identify Project Milestones and Outcome Measures

In order to realize the care coordination initiative for the elderly, it is necessary to define the project’ measures they should have and outcomes to provide a comprehensive picture of the project and its goals. NURS FPX 6618 Assessment 1 goes hand in hand with identifying concrete targets that point to incremental progress towards achieving the big-picture objectives and outcome indicators that are appropriate for capturing the stand-alone value and performance of the respective approach (Counsell et al., 2019).

Project Milestones

The first significant intervention concerning clinical horizons entails the establishment of a durable care coordination model unique to elderly patients. This milestone covers the development of an enhanced and properly formulated model incorporating the data gathered through stakeholders’ involvement and the existing literature review (Anderson et al.,2020). NURS FPX 6618 Assessment 1 Considering the present achievement of attaining this milestone in the initial three months alone after initiating the project, it provides a very good platform for future activities.

The second milestone entails the coordination of agencies and actors according to the context of the intervention. This entails the establishment and coordination of inter-professional relations between healthcare facilities, social and health administration authorities, and other relevant service-delivering firms, community associations, and caregiver support groups (Jackson et al., 2021). It, therefore, makes business sense to have these partnerships set up before the middle of the first calendar year of the project to ensure programme delivery and service integration.

NURS FPX 6618 Assessment 1 Outcome Measures

Among all of the mentioned outcome measures, patient satisfaction and experience would be one of the most important ones. Understanding of how the intervention impacted patient satisfaction with care coordination services or the degree of access to care/communication with providers is best obtained through repeated assessment (Mavrinac et al. , 2021). Another important outcome is monitoring health status and functional assessments. The predictors’ emphasis on tracking indicators that include hospital readmissions, emergency department visits, the rate of falls, and ADL imply that care coordination can have a positive impact on patients’ health and well-being (Iglesias et al., 2019).


NURS FPX 6618 Assessment 1 creation and initialization of a care coordination project outline is an essential marker towards addressing the challenges and enhancing the healthcare administration of vulnerable groups. Reflecting on this assessment, it became clear that meeting the needs of a selected population in terms of organisation of care involves an analysis of all the services that this population receives from multiple agencies. The plan that has been created conforms to the project’s challenge or lack of care coordination, defining of relevant actors and stakeholders, among other sources of funding, and goals or objectives of the project to leave a mark of an achieved tangible successful health promotion project and the tangible goals to be met with definite timelines hence the need to achieve the health promotion project. Therefore, through outlining a clear and concise vision and goal setting, coupled with the process of translating evidence-based practice into an implementation plan, the goal is to increase the quality, accessibility and impact of care.


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