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Coordination and Continuum of Care in Nursing Homes

Understanding continuum and coordination of care

Care coordination has various meanings depending on whose scholar is describing it. However, the basic understanding is that it refers to the appropriate delivery of healthcare services through the organization of several participants, including patients, their families, nurses, physicians, and other medical professionals (Swan et al., 2019). There are three perspectives of care coordination, including the patient or family perspective, healthcare professionals perspective, and system representatives perspective. The patient or family perspective ensures that preferences and needs are met, especially during transitions. Professionals perspective deals with gaps that may arise in information sharing, teamwork, unreasonable effort levels, and poor outcomes (Swan et al., 2019). System representative is the deliberate integration of information, staff, and other resources to prevent care fragmentation.

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Continuum of care involves delivering patient-centered services as the medical condition fluctuates, even across the patient’s lifetime (Swan et al., 2019). Ongoing healthcare services depend on the medical history and current situation of the patient.

Care coordination ring

Care coordination ring

The care coordination ring shows the primary goal at the center, aided by the perspectives. The continuous blue line represents closing of gaps achieved through care coordination while the colored circles are potential participants.

Care in nursing homes

Nursing homes should not be confused with residential care or assisted living services. They provide both residential and nursing care around the clock for people who do not need hospitalization but require more care than can be given at home. The care can be short or long term depending on the patient’s needs, such as severe learning and physical disabilities or terminal illnesses. These centers provide high level of care and hence they hire RNs, licensed practical nurses, and nurse aides to ensure all levels of care are professionally offered. In addition, there is a RN on the site around the clock to provide expert level support to other professional caregivers.

This presentation is directed to Phoenix Mountain Nursing Center.

Phoenix Mountain Nursing Center

Phoenix Mountain Nursing Center (PMNC) is based in Arizona and provides short and long term care to even Medicaid and Medicare beneficiaries. PMNC received below average reviews from government inspection in the cycle ended 2020 and has paid two fines in the last three years (Phoenix Mountain Nursing Center (PMNC), 2021). The inspectors’ findings show that the center does not have an infection control and prevention program, fails to test all its staff and residents for coronavirus, and does not conduct accurate assessments of the residents. Additionally, the center does not meet the patients’ needs in the first 48 hours upon admission and some residents did not receive enough fluids or food for good health (PMNC, 2021). It also failed to offer appropriate care and treatment to meet residents’ goals, orders, or preferences. Another problem was identified in the drug store, where labelling and storage did not follow professional standards. Therefore, PMNC will greatly benefit from the presentation as nurses will learn how to improve in those areas by applying the code of ethics and health policies.

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Code of ethics: provision 3

Provision 3 of the nursing Code of Ethics is applicable in facilitating improvement of the situation at PMNC to ensure care coordination. All existing nurses must adhere to the Provision’s guidelines to protect the rights of their residents. Care coordination and continuum of care is failing due to various problems among nurses. The nurses must embrace ongoing learning to prevent implementing outdated practices, such as those identified in labeling and storing drugs and medical supplies (Olson & Stokes, 2016). The nursing manager at PMNC to ensure that all the personnel in the facility are constantly trained on emerging knowledge.

Continuum of care is disrupted when residents do not receive treatment for 48 hours. Nurses must adhere to Provision 3 requirements by taking legal action to remedy the situation (Olson & Stokes, 2016). By using established mechanisms within the nursing home, nurses must protect the profession, public, and residents by reporting all questionable behavior that prevents care coordination.

Code of ethics: provision 6

Continuum of care is only possible when care is carefully coordinated in the nursing home. Provision 6 directs nurses and nursing executives to choose the right over wrong in care planning and decisions. PMNC must use policies to create an enabling environment for virtuous nurses. To close gaps in the care coordination ring, nurses must support each other’s ability to fulfill their ethical obligations (Olson & Stokes, 2016). If nurses are not treated fairly and equally, continuum of care will not be achieved as part of them might abscond or boycott their duties. Coordination and continuum of care might also be lost during organizational change if collective action and interdisciplinary efforts are not included in the process.

Affordable care act (ACA)

The ACA ensures coordination and continuum of care by including most citizens into insurance plans. PMNC participates in Medicare and Medicaid, which requires the center to adhere to the law while providing services to residents. For example, residents with preexisting conditions require follow up and must be accepted under their insurance plans (Ritter et al., 2021). PMNC must conduct assessment and other check up routines without extra cost to the residents as they are part of the preventive services. The essential health benefits most applicable to PMNC include rehabilitative care, chronic disease management, and emergency services.

Health Insurance Portability and Accountability Act (HIPaA)

The HIPAA seeks to regulate how digital health information is collected, stored, and shared across hospitals and other healthcare facilities. Specifically, it sets national standards by preempting state laws on the accessibility, portability, and renewal of patient data (Peregrin, 2021). Therefore, PMNC can achieve continuum of care by accessing residents’ health information from previous providers and renewing the data where necessary to continue with new care plans. However, the center must uphold existing standards on data integrity and privacy. Care coordination might require all nursing levels to gain access to residents’ data, raising potential privacy and confidentiality pitfalls (Peregrin, 2021). Proper training of personnel on data laws will ensure coordination and continuum of care without attracting lawsuits.

Senate bill 1373

The SB1373 was passed into law in 2021 to ensure that residents receive first aid, basic life support, and emergency care services at the nursing home. The regulations seeks to ensure that continuum of care is achieved and that residents are not deprived of medical care at any instance. In the absence of this rule, nursing homes would wait for ambulatory dispatch to attend the patient, increasing the risk for negative outcome. PMNC must ensure that there are no policies contradicting this requirement, first aid and emergency care personnel are always on the site, and residents’ medical data concerning advance directives are readily available to facilitate decision making. Care coordination will require closing of gaps in knowledge on emergency services, basic life support, and first aid.


PMNC must improve care coordination and continuum to improve its services to residents by applying the Code of Ethics, adhering to ACA and HIPAA, or other state and local policies. The Code of Ethics will guide nurses at all levels and the center management to create suitable environment, work groups, and policies to enhance coordination and continuum of care. HIPAA will also facilitate by enabling PMNC to access medical history of residents to ensure smooth transitioning and continued care.

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Olson, L. L., & Stokes, F. (2016). The ANA code of ethics for nurses with interpretive statements: Resource for nursing regulation. Journal of Nursing Regulation, 7(2), 9-20. Web.

Peregrin, T. (2021). Managing HIPAA Compliance Includes Legal and Ethical Considerations. Journal of the Academy of Nutrition and Dietetics, 121(2), 327-329. Web.

Phoenix Mountain Nursing Center. (2021). U.S. News. Web.

Ritter, A. Z., Freed, S., & Coe, N. B. (2021). Younger Individuals Increase Their Use of Nursing Homes Following ACA Medicaid Expansion. Journal of the American Medical Directors Association. Web.

Swan, B. A., Haas, S., & Jessie, A. T. (2019). Care coordination: Roles of registered nurses across the care continuum. Nursing Economics, 37(6), 317-323. Web.

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