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Discuss about the Nursing Care Coordination ?


Chronic illness not only affects the lives of the people who are affected with it but it also tends to hamper the physical as well as the emotional health of the carers who are taking care of the chronically ill patients. Therefore caring for the chronically ill patients often results in a negative impact on the lives of the family members who have taken the responsibility of caring for their ill members. One must completely develop knowledge on the impacts that the family members may experience when caring for the patients. This is very much important as the researchers suggest that the physical as well as the mental well being of the carer is indeed responsible for the patient’s health (Cameron et al., 2016). It enhance not only the health of the patient but also results in the well fare and successful rehabilitation of the patient suffering from the chronic illness. Therefore, it becomes extremely important for the topic to be discussed for better knowledge of the pressures experienced by the family members while caring for a chronically ill patient at their residences. Therefore the following report will mainly focus on the different types of effects that chronic illness has on the family members. It will also shed light on how the care coordination among different agents can help in reducing the burden that appears on the different carer of the ill patients. It will mainly help to identify the different facilitators and also the different barriers that have potential impacts on care coordination.

In order to search for the best articles that will help to understand various kinds of pressures experienced by the family members and also on the concepts of how proper coordination may help such family members, different search strategy with the correct key words is very necessary. The main search engines which were utilized here contain the Cinahl, pubmed, plos one and also Wiley online library, Google scholar was also used that proved to be very helpful. The keywords that were mainly used for the searching of articles in the search engines were- community nursing, family pressure, burden, chronic illness at home, patients with family carer and pressure on them, emotional well being of carer, physical effect on carer, care coordination, facilitators for care coordination, barriers for care coordination and many others.

Researches conducted by eminent scientists have shown that family members who tend to interact extensively with that of chronically ill patient in their family develop not only physical stresses but also go through severe emotional turmoil (Pietta et al., 2013). Researches show that they suffer from physical exhaustion, stress, poor self care and also are subjected to mood swings and different types of mood disorders. They also go through various physical disturbances that make them suffer from various health conditions that involve high cholesterol, hypertension, depressed immune system and many others. It is necessary for the carer to understand what they need to carry for themselves to derive the strength for providing palliative care.This is important because it would help to meet the needs of their patients which in turn create more burdens on the caregiver (Nielson et al., 2016). A number of various factors have been reported by the carer who acts as the contributors to the stress of carer. Lack in proper education and skill for caring a chronically ill patient and lack of assistance from healthcare professionals are some of them (Kendell et al., 2014).  Absence of proper social support and increasing stress with continuously advancing disease stages thereby create burden. Researchers also suggest that the physical and mental health stability of the caregiver is very important because the behavior and the attitude of a caregiver often influence the psychological adjustment that a patient prepares with his illness and also denotes the behaviors of the patients that either results in promotion of his health and delay recovery resulting in prolonged adherence to treatment (Adelman et al., 2014). Therefore it becomes extremely important for them to take the assistance form health care professionals, who will mainly help in the coordination of the care and thereby provide support to the family members through thorough education with the provision of resources and also help in communication.


Researchers over the years have stated that care coordination helps in including a large number of aspects of health care provisions which are provided by multidisciplinary team that comprises of community based social service providers along with medical and nursing teams. It is already established that even after the release of the patient from the hospitals, the caregivers and also the family members continue to face different types of challenges while accepting and giving care respectively (Burgio & Gugler, 2016). Therefore it is the crucial role of the team of the care coordinators to assist the family carers to overcome the different challenges that they face. This team helps the caregivers to identify the different aspects where they are losing their confidence to provide care and accordingly help them in gaining strength and realizing ways to promote such strengths. It also help them to get involved in certain reflective mode of thinking situations which help them to understand which part of their life is affected and in which way so that they can try to make it better and also help in adapting to the los they have faced (Osborn et al., 2014).

Community health and home health nurses can help the family caregivers by assessing their mental and physical well being, employment status, resources available, and also their feelings at a regular basis when they would come as primary care visits. First they should try to engage the caregivers in discussions trying to know their experiences of sadness, depressions, irritability, insomnia, decreased appetite and others. These should be followed by them to give references to the caregiver to different resources like social worker, care manager or even social care services to provide support to them (Cramm & Nieboer, 2016). In many cases also it has been seen that the general practitioners who treats the patients with the chronic illness also remains aware of the burden that the family member is facing while giving care to him (Coleman et al., 2015). They can easily understand the different types of resources that can help the family member of the patient and refer accordingly. Often the nutritional need of the carer gets neglected under the burden of the carer. The community nurses and the GP can assess such needs and accordingly refer them to the dieticians. Then the dieticians will educate the caregivers about the correct nutritional requirement needed by them so that they can overcome the challenges of caring.

Chronic patients are those who is suffering from some particular disease for more than three-six months. They are being treated by the senior doctors and can be taken care by the nurses or the care coordinators (Bronstein et al., 2014). Care coordinators can be hired from the rehabilitation centres. For any particular patient suffering from chronic illness are need to be taken care by the family members for their fast recovery.


Care coordinators need to assemble the necessary documents of the patients suffering from chronic illness. They need to forward those to their higher authority or the specialised medical practitioners. The care coordinators need to coordinate and regulate the team meeting and to gather the information that must be required for the recovery of the patient suffering from a particular chronic illness (Aronson, Bautista & Covinsky, 2015).

The point of this article is to basically break down and examine the present writing identified with the family weights of constantly sick customers at home. This subject is worth to talk about as a broad group of research recommends that constant ailment influences not just the lives of those misery from ailment additionally the relatives who administer to them (Fullerton et al., 2016). Taking care of the effects of incessant disease on relatives is imperative in light of the fact that the physical and enthusiastic wellbeing of family guardians can possibly impact the wellbeing, great admission and fruitful recovery of people with such endless sickness. In this way, a critical point of this article is to talk about the impact of perpetual sickness on parental figures. Another point of this paper is to clarify the part of care coordination to mitigate trouble from relatives taking care of constantly sick customers in their homes. The part of all work force required in care coordination is will be clarified and the significance of correspondence among them will be talked about. In addition, the facilitators and boundaries to care coordination will likewise be recognized (Bautista, Covinsky & Aronson, 2015).

Look into has demonstrated that giving consideration to an incessantly sick relative can effectively affect the guardian's mental wellbeing and physical prosperity over a timeframe. The relatives of patients who fill in as parental figures are more inclined to state of care unsettling influences, physical weariness, stretch, poor self-care, and other wellbeing conditions, for example, hypertension, elevated cholesterol, and discouraged invulnerable framework. Parental figures frequently additionally are required to give up their own needs to address the issues of the relative, and this can expand guardian load advance. The family parental figures regularly report shortfalls in instruction and abilities identified with the patients care, an absence of help from medicinal services experts, a nonattendance of social support, and expanding stress related with the patient's propelling ailment condition. The families impact a patient's mental acclimation to the disease, adjustment of practices that advance or defer recuperation and adherence to treatment. Thus, the relatives overseeing patients with perpetual diseases at home require human services experts to facilitate care and render bolster through training, assets and correspondence.


Care coordination includes various parts of wellbeing administration arrangement gave by a multidisciplinary group involving restorative, nursing and group based social specialist co-ops. It is imperative for clinicians to understand that parental figures and patients keep on facing huge difficulties long after they are released from doctor's facility and they require ceaseless observing. The critical part of the care coordination group is to guarantee that family carriers are helped to meet the difficulties of care. Care facilitators help the carriers to nearly look at the impacts of care-giving on their lives and help them recognize qualities that elevate adjustment to misfortune. Besides, care coordination connects with patients and families in intelligent discourse about how disease has changed their conditions and proposes techniques to defeat the anxiety postured via care giving.

Care coordination envelops various parts of wellbeing administration arrangement gave by a multidisciplinary group including medicinal, nursing and group based social specialist organizations. It is essential for clinicians to understand that parental figures and patients keep on facing noteworthy difficulties long after they are released from healing facility and they require persistent checking. The urgent part of the care coordination group is to guarantee that family carriers are helped to meet the difficulties of care (Taylor et al., 2013

A general expert in essential social insurance administrations mainly acts as a “guard” who eludes the patients to other human services authorities and is in-charge of care coordination (Friedman et al., 2016). General professionals frequently have long haul associations with incessantly sick patients and their families, in this way, they can without much of a stretch recognize parental figures' anxiety and allude them to fitting administrations. For example, it is likely that parental figure weight may keep some carriers from perceiving their own particular nourishing needs. GP or group medical attendants may effortlessly evaluate the parental figures' wholesome needs and elude them to dietician who may teach the guardians about the significance of having an adjusted eating regimen to meet the difficulties of caring.

Care coordination is a significant component of giving viable care to the parental figures, notwithstanding, there are sure facilitators and obstructions to care coordination. Multidisciplinary group gatherings are viewed as an indispensable part to provide facilitated and community care. Powerful correspondence among care suppliers amid these gatherings encourages care coordination; in any case, these gatherings are not executed as reliably or effectively as prescribed prompting to absence of care coordination. There are a few obstructions to the powerful execution of these gatherings, for example, time imperatives, absence of managerial support for these gatherings and predominant identities constraining open dialogs. Coordination is improved through correspondence that spotlights on critical thinking as opposed to faulting. In human services settings, members regularly point the finger at each other when blunders happen; be that as it may, accusing undermines coordination by making data stay covered instead of being shared (Scholz & Minaudo, 2015). What can be more other than sharing the regards among members likewise escalate coordination, in any case, individuals from various word related groups may strengthen their own status by developing lack of regard for the work performed by others successful administration and administration framework is a solid facilitator of care coordination. Moreover, devoted time and assets, great correspondence and data sharing among staff, and attention to the formal of cooperating may likewise upgrade coordination.


Taking everything into account, as the quantity of constantly sick patients increment in the public eye, it is imperative that the associated wellbeing group comprehend the family care supplier. The people group wellbeing and home wellbeing medical attendants are in a flawless circumstance to lessen weights on the relatives of incessantly sick patients at home (Friedman et al., 2016). By evaluating and understanding the issues, the care coordination group can give intercessions that will be proactive and avoid additionally worry in the life of the caregiver, customer, and family. There are facilitators and hindrances to viable care coordination. Certain components, for example, shared learning, common regard, and top notch correspondence that is opportune, regular and critical thinking may encourage care coordination. In actuality, absence of time, absence of regard towards different experts, pointing the finger at each other, absence of regulatory support to the gatherings, predominant identities restricting talk are a portion of the hindrances to care coordination (Scholz & Minaudo, 2015). Additionally research is expected to defeat these hindrances and execute procedures to bolster caregivers.



Adelman, R. D., Tmanova, L. L., Delgado, D., Dion, S., & Lachs, M. S. (2014). Caregiver burden: a clinical review. Jama311(10), 1052-1060.

Aronson, L., Bautista, C. A., & Covinsky, K. (2015). Medicare and care coordination: expanding the clinician’s toolbox. Jama, 313(8), 797-798.

Bautista, C. A., Covinsky, K., & Aronson, L. (2015). Chronic care management for Medicare patients—Reply. Jama, 313(22), 2286-2287.

Bronstein, L. R., Gould, P., Berkowitz, S. A., James, G. D., & Marks, K. (2015). Impact of a social work care coordination intervention on hospital readmission: a randomized controlled trial. Social work, 60(3), 248-255.

Burgio, L. D., & Gaugler, J. E. (2016). Caregiving for the chronically ill: state of the science and future directions. The Spectrum of Family Caregiving for Adults and Elders with Chronic Illness, 258-278.

Cameron, J. I., Chu, L. M., Matte, A., Tomlinson, G., Chan, L., Thomas, C., ... & Ferguson, N. D. (2016). One-year outcomes in caregivers of critically ill patients. New England Journal of Medicine374(19), 1831-1841.

Coleman, E. A., Roman, S. P., Hall, K. A., & Min, S. J. (2015). Enhancing the Care Transitions Intervention protocol to better address the needs of family caregivers. Journal for Healthcare Quality37(1), 2-11.

Cramm, J. M., & Nieboer, A. P. (2016). The changing nature of chronic care and coproduction of care between primary care professionals and patients with COPD and their informal caregivers. International journal of chronic obstructive pulmonary disease11, 175.

Friedman, A., Howard, J., Shaw, E. K., Cohen, D. J., Shahidi, L., & Ferrante, J. M. (2016). Facilitators and barriers to care coordination in patient-centered medical homes (PCMHs) from coordinators' perspectives. The Journal of the American Board of Family Medicine, 29(1), 90-101.

Fullerton, C. A., Henke, R. M., Crable, E. L., Hohlbauch, A., & Cummings, N. (2016). The Impact Of Medicare ACOs On Improving Integration And Coordination Of Physical And Behavioral Health Care. Health Affairs, 35(7), 1257-1265.

Kendall, M., Carduff, E., Lloyd, A., Kimbell, B., Cavers, D., Buckingham, S., ... & Sheikh, A. (2015). Different experiences and goals in different advanced diseases: comparing serial interviews with patients with cancer, organ failure, or frailty and their family and professional carers. Journal of pain and symptom management50(2), 216-224.

Nielsen, M. K., Neergaard, M. A., Jensen, A. B., Bro, F., & Guldin, M. B. (2016). Psychological distress, health, and socio-economic factors in caregivers of terminally ill patients: a nationwide population-based cohort study. Supportive Care in Cancer24(7), 3057-3067.

Osborn, R., Moulds, D., Squires, D., Doty, M. M., & Anderson, C. (2014). International survey of older adults finds shortcomings in access, coordination, and patient-centered care. Health Affairs33(12), 2247-2255.

Piette, J. D., Rosland, A. M., Marinec, N. S., Striplin, D., Bernstein, S. J., & Silveira, M. J. (2013). Engagement with automated patient monitoring and self-management support calls: experience with a thousand chronically-ill patients. Medical care51(3), 216.

Scholz, J., & Minaudo, J. (2015). Registered Nurse Care Coordination: Creating a Preferred Future for Older Adults with Multimorbidity. OJIN: The Online Journal of Issues in Nursing, 20(3).

Taylor, E. F., Machta, R. M., Meyers, D. S., Genevro, J., & Peikes, D. N. (2013). Enhancing the primary care team to provide redesigned care: the roles of practice facilitators and care managers. The Annals of Family Medicine, 11(1), 80-83.


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