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Ethical and Policy Factors in Care Coordination (Script)

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Script

Slide 1 – Title Slide

Welcome to this presentation on ethical and policy aspects of care coordination. As

nurses provide care-coordination we need to be aware of how health policies, our professional

ethics, and advocating for the patient are interdependent as we transition through each level of

care. While working in the community setting, we help patients navigate the complexities of

their insurance; they have to refer them to other health care professionals; they have to maintain

confidentiality regarding their medical information; and they have to know where to find

resources within the community.

Slide 2 – Overview

As care coordinators we are working at an intersection of patient needs, the demands of

the institution we are working in, and the public policy that exists around that care. Our

understanding of how policies exist impacts our ability to assist patients in understanding what

they are eligible for; what reimbursement system exists for the care they receive; what type of

protections exist for their private medical information; and what types of rights exist to ensure

their safety. As nurses, having a sense of ethics enables us to think critically when there are

conflicts between what we believe to be best for the patient's well-being versus what is required

by the policies and regulations of the organization we represent. According to the American

Nurses Association (ANA), 2022, "nurses have a responsibility to uphold human dignity, protect

the rights of individuals, and advocate for safe care." By being informed ethically and based

upon policy we are able to enhance patient access to services; minimize gaps in care; promote

quality of care; and strengthen our role as advocates for patients in all community care settings.

Slide 3 – Governmental Policies and Care Coordination

Federal and state governments develop policies that dictate what services patients are

allowed to access, and how care coordination services are provided. For example, Medicare and

Medicaid pay for many coordination services. CMS has developed Chronic Care Management

Codes to enable ongoing management of patients who have multiple chronic conditions. HIPAA

dictates that patient confidentially must be maintained and defines under what circumstances

providers may share protected health information with one another. EMTALA requires providers

to treat emergency patients regardless of whether or not they have insurance coverage. Since this

creates additional coordination responsibilities after emergency treatment is received, EMTALA

serves as a critical component in coordinating post-acute care. Additionally, Healthy People 2030

outlines national priorities related to healthy living. Finally, Reddivari (2023) asserts that the

Affordable Care Act (ACA) supports the development of accountable care organizations

(ACOs); ACOs hold participating healthcare providers financially responsible for the total cost

of care for all patients with whom they interact.

Slide 4 – Affordable Care Act Provisions

The Affordable Care Act (ACA) has been instrumental in changing the manner in which

care coordination services are reimbursed. Isola and Reddivari (2023) note that the ACA created

opportunities for increasing coverage options; strengthening prevention strategies; and

incentivizing coordinated, value-based care. ACOs provide incentives for participating providers

to work together to coordinate patient services. Patient Centered Medical Homes (PCMHs)

provide a mechanism for primary care services to be coordinated across different locations.

Medicaid expansion was passed into law prior to full implementation of the ACA.

Slide 5 – National Policy Provisions and Ethical Questions

When national policies dictate how services should be provided, it often raises ethical

issues as standardized rules may not apply equally to every individual patient's situation. For

instance, Medicaid prior authorization processes can delay medically necessary referrals that

could positively impact patient health, thereby raising questions concerning fairness (justice) and

doing good (beneficence). Payment models designed to incent high-quality care may favor

patients with fewer comorbidities at lower costs, potentially harming those patients with complex

or expensive-to-treat illnesses. HIPAA ensures patient privacy is maintained; however, it limits

timely communication between healthcare providers during transitional phases of care. Penalties

associated with hospital readmissions can lead institutions to prioritize discharging patients

quickly over safely transitioning them from acute to ambulatory care environments. Larsen

(2024) states that such dilemmas require thoughtful ethical consideration in nursing practice.

Slide 6 – State and Local Policy Provisions

State and local policies introduce additional ethical considerations into the realm of care

coordination. Policies at the state level can influence the degree of independence that RNs have

in initiating referrals and coordinating services based on their respective scopes of practice. State

Medicaid benefit design determines what home- and community-based services will be paid for.

Reporting mandatory laws can sometimes present dilemmas for nurses regarding their

obligations to report certain conditions versus maintaining patient confidentiality. Mandates from

local health departments govern priority areas within each community such as vaccinations and

infection prevention. Housing regulations and community benefit programs from hospitals also

support aspects of patient care. Oruche and Zapolski (2020) make the case that these factors

relate to health equity.

Slide 7 – Implications and Consequences

Both positive and negative implications arise due to provisions included in healthcare

policies. ACO's shared savings models promote coordinated care; however, they may

disincentivize physicians from providing care to high-cost patients. Medicaid Managed Care can

control cost while limiting physician choices. Preventative Care mandates provide incentives for

earlier interventions; however, patients who are under-insured may still experience some gap.

Chronic Care Management supports care for complex patients; however, it has limitations to

eligibility. PCMH promotes team-based care among all members involved; however,

implementation of this model may vary significantly depending upon the community where it is

being implemented. Larsen (2024) argues that nurses need to consider both the intent and

unintentional consequences of various policies.

Slide 8 – Code of Ethics for Nurses

The ANA Code of Ethics is the basis for nurses' professional ethics in terms of care

coordination. All nurses must practice with "compassion" and show "respect for every person's

dignity, worth, and uniqueness." The ANA Code states that a nurse's first responsibility is always

to the patient (or patients), regardless if it is one patient, a family unit, a group, or even a larger

community. The code requires nurses to advocate for the rights, safety, and well-being of their

patients. The Code of Ethics helps define how nurses decide about referrals, communication,

resource allocation, accountability, and working together with other disciplines/organizations as

part of coordination.

Slide 9 – Impact of the Code on Care Coordination

The ANA Code of Ethics informs how nurses carry out care coordination across different

levels of care. Provision 3 advocates for patients by mandating protection of patients' rights and

promotion of their access to appropriate services. Provision 2 ensures that patients continue to be
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engaged participants in decision-making related to their own care through its emphasis on

patient-centeredness. Provision 8 promotes collaboration between nurses and other

professionals/communities. These principles are particularly relevant for vulnerable populations.

As argued by Oruche and Zapolski (2020) nurses have an important role to reduce inequalities

and advance health equity.

Slide 10 – Health Disparities and Access

Health disparities impact the results of care coordination. Many barriers exist for patients

including but not limited to those created by race, ethnic background, income level, geographic

location, insurance coverage status, and ability to understand their health. For example low-

income individuals often have challenges accessing transportation, paying for medications,

obtaining stable housing, and continuing follow up appointments. Individuals living in rural

settings may have few available providers in close proximity as well as long travel times. Those

with limited health literacy may misinterpret their care plan or misunderstanding instructions

regarding their medication. Oruche and Zapolski (2020) argue that nurses should intervene

against these barriers through advocacy, cultural competent communication strategies, and

connections to community resources.

Slide 11 – Key Ethical and Policy Issues

To summarize care coordination relies on both policy knowledge and ethical reasoning.

Payers at the federal, state and local levels determine many aspects of patients' access to services,

payment for services, privacy, referrals, etc., while simultaneously creating potential obstacles

through delayed delivery of services, restricting access, or unequal distribution of resources. The

ANA Code of Ethics serves as guidance for nurses when patients' needs conflict with

requirements stated in policies. The American Nurses Association (2022) identifies three
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components that nurses must maintain for ethical care coordination: advocating for patients'

dignity, protecting patient safety, and promoting patients' rights. Therefore, ethical care

coordination necessitates advocacy for patients, collaboration among healthcare

professionals/providers, equitable practice approaches focused on health equity concerns within

communities and effective utilization of community resources.

Slide 12 – References

American Nurses Association. (2022). Code of ethics for nurses with interpretive statements (2nd

ed.). American Nurses Association.

Isola, S., & Reddivari, A. K. R. (2023, July 10). Affordable Care Act. StatPearls - NCBI

Bookshelf. [Link]

Larsen, S. (2024). Ethical Dilemmas in Nursing: Navigating complex patient care scenarios.

[Link]. [Link]

dilemmas-in-nursing-navigating-complex-patient-care-scenarios- [Link]

Oruche, U. M., & Zapolski, T. C. B. (2020). The role of nurses in eliminating health disparities

and achieving health equity. Journal of Psychosocial Nursing and Mental Health

Services, 58(12), 2–4. [Link]