How nurse leaders can improve care coordination

The role of care coordination and transition management is gaining more and more attention for its potential in helping achieve the Triple Aim of healthcare: improving quality, improving the health of communities and cutting costs. For nurse leaders wondering how to best encourage and implement comprehensive care coordination and transition management services in their facilities, the American Academy of Ambulatory Care Nursing (AAACN) and the American Organization of Nurse Executives (AONE) issued a joint statement with advice it considers essential.

“Registered nurses are the largest group of frontline health care professionals. That’s why it is crucial for nurse leaders to take initiative and prepare their delivery systems and nursing staff for care coordination and transition management,” said Pamela Thompson, MS, RN, CENP, FAAN, CEO of the American Organization of Nurse Executives and senior vice president for nursing at the American Hospital Association.

“The principles in the joint statement will help guide leaders in acute and outpatient settings to achieve the best patient experience and outcomes.”

Bridging  gaps

Cynthia Nowicki Hnatiuk, EdD, RN, CAE, FAAN, CEO of AAACN, called the joint statement historic, “because it bridges the traditional silos between acute care and ambulatory care nursing, thereby forging ground on a seamless patient experience throughout the continuum of care."

The goal of care coordination and transition management is to ensure patients aren’t frustrated or lost trying to navigate the healthcare system and, consequently, slip through the cracks.

"Care coordination is a role that synchronizes all aspects of patient care,” Dr. Hnatiuk said, “from admission to discharge home or to another care setting, and follow up with other care providers.”

Six steps to success

The “Joint Statement: The Role of the Nurse Leader in Care Coordination and Transition Management across the Health Care Continuum” is made up of a half-dozen strategies to guide nurse leaders in establishing collaborative care coordination processes. Here’s a rundown of the recommendations.

1. Know how care is currently coordinated in your setting. This includes understanding your patient population, its needs and resources, as well as having a real-world grasp of a typical journey through the healthcare system. Also, understand the current infrastructure for patient transitions.

"As a nurse leader, it's important for you to be very well-versed on that transition of care model and be integral in development and refinement of that," said Claire Zangerle, MSN, MBA, RN, president and CEO of the Visiting Nurses Association of Ohio, at a session about the joint statement at this spring’s American Organization of Nurse Executives annual conference in Fort Worth, TX, according to HealthLeaders.

2. Know who is providing care coordination and transition management activities in your organization, and define their roles and responsibilities. Patients can be confused about overlapping roles of transition coaches, care coordinators, case managers and whatever other professionals have evolved to play a role in this increasingly recognized aspect of care.

"Focus on eliminating the redundancy in roles and ensure they're well-defined so those within the team and those outside the team can understand," Zangerle said in the HealthLeaders article.

3. Establish relationships to improve care coordination. Identify leaders from across the care continuum as well as external shareholders, and create a shared vision for care coordination.
4. Know the value of technology and optimize it for better coordination of care. Work with information technology staff on data analytics to capture outcomes and identify high-risk patients that could benefit from care coordination.
5. Engage the patient and family in care coordination as well as process improvements. Include them on advisory boards, survey results reviews and decisions on how to improve care coordination.
6. Engage team members. Choose a nurse leader and a physician leader to lead care coordination efforts as a team. Educate leaders and staff on the value of care coordination and the difference it can make.

Care coordination isn’t going anywhere. If organized effectively, the process offers huge benefits for patients, payers and providers.

Lippincott Solutions, the leading provider of institutional, evidence-based clinical software, has partnered with AAACN to develop a new ambulatory care nursing category for Lippincott Procedures—the best-in-class online procedures resource for nurses and other clinicians at the point-of-care and in competency management.