Care Coordination

Gerri Lamb, PhD, RN, FAAN is a well-known speaker and author on care coordination and case management. She edited ANA’s Care Coordination: The Game Changer, one of the first books to explore the many facets of nurse care coordination in the context of massive health system transformation. Dr. Lamb is Professor and Director of the Center for Advancing Interprofessional Practice, Education and Research at Arizona State University’s College of Nursing and Health Innovation. Writing this Blueprint for Action with Robin Newhouse combines two of her favorite topics: care coordination and interprofessional practice. She serves as a content expert on care coordination practice and measurement for several national professional and health care organizations. Robin Newhouse, PhD, RN, NEA-BC, FAAN is a renowned nurse researcher, author, and educator. Her research focuses on health system interventions to improve care processes and patient outcomes; she has published extensively on health services improvement interventions, acute care quality issues, and evidence-based practice. Dr. Newhouse is Distinguished Professor and Dean of the Indiana University School of Nursing, and serves on national and professional health care organizations. Writing this book with Gerri Lamb combines two of her favorite topics: evidence translation and measuring the effect of nursing processes on patient outcomes.

About the Authors
Part I: A Care Coordination Blueprint for 21st Century Nurses
Chapter 1: An Action-Oriented Approach to Care Coordination for Today’s RNs
The Background for This Blueprint
Care Coordination: Its Coming of Age
Care Coordination Now: What Brought Us Here
Care Coordination Going Forward: Nurses Leading the Way
Care Coordination and Nursing Today: If Not Us, Who?
A Blueprint for Moving Forward
The Parts of This Blueprint
Central and Actionable Issues
Six Actionable Issues
Why These Six Issues?
Framing the Actions
The Blueprint’s Audience
Getting into Blueprint Thinking: Some Resources
References
Chapter 2: Care Coordination in Health Care Today: The Context and Framework for the Blueprint
Framing Care Coordination: Central to Achieving U.S. Quality Goals
Defining Care Coordination: Toward a Baseline for Nursing’s Contributions
The AHRQ Definition
The NQF Definitions
A Synthesis of the Definitions
Defining Care Coordination, Validating Nursing
Six Issues That Will Shape the Future of Nurse Care Coordination
Engaging Patients, Families, and Caregivers
Demonstrating Competence and Readiness for Care Coordination Practice
Optimizing Teams and Teamwork for Care Coordination
Using Documentation and Health Information Technology in Care Coordination
Measuring Care Coordination
Paying for Care Coordination
Bringing the Issues Together: Small Actions Leading to Big Differences
References
Part II: The Blueprint’s Six Action Issues
Action Issue 1: Engaging Patients, Families, and Caregivers in Care Coordination
Understanding Patient Engagement in Care Coordination
What Do We Know?
Activated Patients as Engaged Patients
Patient Engagement in Care Coordination and Nursing
What Is Trending?
What Can RNs Do?
Specific Actions for RNs
Summary and Highlights of Action Items
References and Resources
Action Issue 2: Demonstrating Competence and Readiness for Care Coordination Practice
Claiming Professional Competence
Competence and Professional Accountability
What Do We Know?
Care Coordination Competencies for All RNs
Care Coordination Competencies for Specific Practice
Settings: Ambulatory Care
Care Coordination Competencies for Prelicensure Students
Specialty Coordination Competencies and Certification
What Is Trending?
What Can RNs Do?
Specific Actions for RNs
Summary and Highlights of Action Items
References and Resources
Action Issue 3: Optimizing Teams and Teamwork for Care Coordination
Nurse Care Coordinators and the Health Care Team
What Do We Know?
Effective Teamwork Necessary for Effective Care Coordination
Care Coordination and Teamwork Outcomes Aligned
Interprofessional Education and Care Coordination
What Is Trending?
Nurses on Primary Care Teams
The Role of Nurse Care Coordinators on Interprofessional Teams
Emerging Team-Based Models for Care Coordination
What Can RNs Do?
Specific Actions for RNs
Summary and Highlights of Action Items
References and Resources
Action Issue 4: Using Documentation and HIT in Care Coordination
Harnessing HIT to Capture and Document Nurse Care Coordination
HIT Structures
Two HIT Initiatives
What Do We Know?
Data Sets and Infrastructure for Care Coordination
Documentation Standardization and HIT
Interoperability
HIT Resources Needed for Care Coordination
What Is Trending?
Availability and Use of EMRs
Data Analytics and Decision Support
Automating Complex Processes
What Can RNs Do?
Specific Actions for RNs
Summary and Highlights of Action Items
References and Resources
Action Issue 5: Measuring Care Coordination
Care Coordination Measures Essential to Demonstrating and Improving Quality
What Do We Know?
Quality Measures in Care Coordination
Three Main Types
Beyond Quality Improvement
Different Types of Measures for Different Purposes
QI and Research Measures in Care Coordination
Performance Measures in Care Coordination
The Status of Care Coordination Measurement
What Is Trending?
Nurse Involvement with Care Coordination Measures
Care Coordination Measures: Payment and Public
Reporting
Identifying and Attributing Who Contributes to Outcomes
What Can RNs Do?
Specific Actions for RNs
Summary and Highlights of Action Items
References and Resources
Action Issue 6: Understanding Payment in Care Coordination
Payment and Reimbursement for Nurse Care Coordination
What Do We Know?
Payment for APRNs
Restrictions on APRN Scope of Practice
Payment for Registered Nurses
What Is Trending?
What Can RNs Do?
Specific Actions for RNs
Summary and Highlights of Action Items
References and Resources
Part III: Designing Your Own Blueprint for Action
The Stage Is Set: RNs, Take Your Places
RNs Taking Action: Taking Issues into Your Own Hands
Action Issues and Items: A Recap
Action Issue 1. Engaging Patients, Families, and Caregivers in Care Coordination
Action Issue 2. Demonstrating Competence and Readiness for Care Coordination
Action Issue 3. Optimizing Teams and Teamwork for Care Coordination
Action Issue 4. Using Documentation and HIT in Care Coordination
Action Issue 5. Measuring Care Coordination
Action Issue 6. Paying for Care Coordination
Wrapping Up, Looking Forward
References
Index