Addressing Barriers and Leveraging Strengths in Care Coordination_ee48a8a3-f822-40d3-add2-fc80c2454b73.pptx

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1. WELCOME EVERYONE!

2. ADDRESSING BARRIERS AND LEVERAGING STRENGTHS IN CARE COORDINATION Bridging the Gaps: Coordinated, Continuous, and Compassionate Care for Better Patient Outcomes By: MARIA TERESA R. FAJARDO, PhD, EdD, MAN

3. CARE COORDINATION IBU MARIA

4. Empowers patients by involving them in shared decision-making and simplifying navigation. Patient Satisfaction Ensures patients experience smooth transitions between providers, settings, and treatments. Reduces hospital readmissions and complications through proactive, aligned care planning. Improving continuity, outcomes, and patient experience Continuity of Care Better Health Outcomes Why Care Coordination Matters? AT IT'S HEART…IS ABOUT CONNECTION

5. ZOOM POLL Who in your care setting is most responsible for ensuring follow up care after discharge? A. Nurse? B. Doctor? C. Family? D. No one is clearly assigned? Care coordination matters because: Poor coordination= medical errors, readmissions, confusion. Good coordination=safety, satisfaction, and healthier outcomes.

6. Common Barriers to Care Coordination Communication Gaps The root of most coordination failures. Care Transitions are High- Risk Moments is a moment of vulnerability Workforce Shortages Lack of Integrated Health Information Systems Limited Training in Care Coordination

7. Solutions and Innovations - What We Can Leverage Embrace the Case Management Model Use SBAR for Standardized Communication Build Interprofessional Collaboration Adopt Digital Tools Strengthen Leadership Support

8. Best Practices and Innovations • Singapore Model: Nurses follow high-risk patients for 30 days after discharge- with calls, visits, and connections to community resources. • Nothern Luzon: Barangay Health Workers trained by nurses use mobile apps to track hypertensive patients' blood pressure and send reports to nurse supervisors • Nursing Schools: Some programs are now integrating SBAR simulations, interdisciplinary teamwork, and discharge planning into clinical courses.

9. Reflective Prompt: What is effective care coordination to you? What is one action can you make to improve care coordination?

10. Effective Care Coordination Mean… • Empathy : Understanding patients' lived experiences and personal goals. • Teamwork : Every member plays a part- mutual respect and trust are foundational. • Continuity : Care that flows without disruption across settings and stages.

11. Building Meaningful Connections Empowering collaboration for better care outcomes . Let’s go back to Nanay Maria or Ibu Maria.. She did not need more meds. She may just need a nurse to connect the dots. That nurse could be YOU. That leader could be US.

12. THANK YOU