FUNDAMENTAL PRINCIPLES OF CARE COORDINATION 1

Fundamental Principles of Care Coordination

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Fundamental Principles of Care Coordination

1. Definition and role of care coordination

1.1. Definition

NEJM Catalyst, (2018) defines care coordination as an approach that synchronizes the

delivery of patient’s health care from a different specialists and providers. Fig 1 summarizes

NEJM Catalyst, (2018) definition of care coordination. The author also views care coordination

as a team sport however its success us dependent on availability of resource, culture and

leadership to support communication, synchronized efforts among the multidisciplinary

specialists and providers. Swan et al., (2019) defines care coordination as the hallmark of health

care reforms in the United States.

Fig 1: Coordination Care definition adopted from NEJM Catalyst, (2018).

1.2. Role

The primary goal of coordinated care is to improve health outcome by ensuring that care

comes from disparate providers. (NEJM Catalyst, 2018) claims that coordinated care ensure that

care is not delivered in silos and cost associated with it are reduced by eliminating redundant

procedures and tests. The approach has allowed health care services to shift from financial risk

amid towards value-based care. RNs provide effective care coordination occurring at varied

population in different settings across care continuum (Swan et al., 2019).

2. Element of care coordination

According to NEJM Catalyst, (2018) the elements of care coordination include;

i. It has easy access to different types of health care providers and services. Bean,

(2017) defines the element as medical reconciliation to ensure that there is efficient transitions

and with more handoffs between skilled nursing facility and acute care staff. Warm-hands

ensures that primary care providers meet face-to-face with members from the post-acute care to

discuss the transition process and review the patient’s care order.

ii. Integrates good communication and effective care plan between providers

iii. Patient- centered allowing it focus on the total health care needs of the patients.

Furthermore, it ensures that the patient risk level are coordinated and condition and ability for the

patient to engage in self-management is achieved.

iv. Lays information in a clear and simple approach which the patient understands.
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3. Levels of care coordination

3.1. Primary care coordination

The primary care coordination is adopted by health care providers dealing with patients

with chronic diseases and conditions such as high-cholesterol and diabetes. The approach was

adopted to solve the growing aging challenge in America. The approach follows the guided care

model where a registered nurse (RN) is given the responsibility of patients with multiple chronic

conditions (NEJM Catalyst, 2018). The RN conducts initial assessment of the patient and

collaborates directly with primary care develop a care plan while coordinating with specialty

care with other providers to ensure that nothing is skipped and the plan is followed.

3.2. Acute Care Coordination

Conditions such as acute health problems (heart attack or stroke) require complex level of

care due to the emergency and critical nature of their condition. Furthermore, the conditions

don’t have predetermined time of occurrence therefore they can catch someone in an off-guard

situation (NEJM Catalyst, 2018). The patents might receive emergency medical services and

hospital outside their regular networks. The risks in redundancies, communication errors and

medical errors can increase when different health care providers are included in the process.

However, with acute care coordination coordinated and synchronized health care is adopted to

ensure that the best clinical results are achieved. The approach is designed in manner that even

upon the patient’s discharge RNs confirm the existence of proper transition of care by making

dure prescription medicine are filled at the pharmacy, and follow-up visits are scheduled. It also

ensures that there us a review of follow-up instructions with the family members and loved ones.

The objective of these efforts is to ensure that there are reduced hospital readmissions rate,

mortality rates and avoidable ER visits.

3.3. Long-Term/ Post-Acute Care Coordination

The approach target patients in rehabilitation, post-acute care (PAC) or long-term care

(LTC) facilities who might need between facilities or varied levels within the health facilities as

their health condition changes (NEJM Catalyst, 2018). Bean, (2017) reviews an AHA study

which claimed that patients admitted in PAC setting are later transferred to a second PAC setting

Although rapid discharge from PAC has been observed readmission has contributed to high-

mortality rates. Readmission risk factors might signify a mismatch between PAC resources and

patients needs or inadequate transitional care processes. Successful models have been

characterized by social workers working with patients and their loved ones and ensuring that

everyone understands the care plan and related expectations. Social workers also work as patient

advocate to ensure that they receive best quality life as possible and provide referral services

available through their facility.

4. Perspectives of care coordination

The basic component of the success of care coordination is that RNs provide it as an

intervention which integrates varied perspectives such as individual, professional and

community.

4.1. Individual Perspective

It’s the RN’s responsibility to understand that every individual has varied needs when it

comes to coordination. Individuals bring predisposing characteristics such family resources,

social structure, health beliefs, culture, self-perceived illness, physiological characteristics that

affect the care coordination (Swan et al., 2019). Furthermore, it’s critical to understand that it’s
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not the number of diagnoses that creates the need for care coordination but complexity of social

and health problems.

4.2. Provider Perspective

People with chronic illnesses need social support and complex care thus they are high

users of community, health and social services. Although care coordination integrates varied

health professions it is evidence that RNs are qualified to provide safe and quality coordination

regardless of practice setting (Swan et al., 2019). Accountability is a requirement for RNs

whether they are employed at as care coordinators or om their RN role.

According to Swan et al., (2019) RNs with competencies from evidence-based dimension

they provide care coordination and transition management practices that include;

I. Coaching and counselling of families and individuals

II. Population health management

III. Collaboration and teamwork

IV. Nursing process

V. Person-centered care planning

VI. Education and engagement of families and individuals

VII. In telehealth RNs provide decision support, information systems and

technologies for all dimensions of care coordination.

VIII. Guide acute practice

IX. Provision of surveillance and support of individuals with multiple chronic

diseases who live at home in assisted living. RNs also ensure that these individuals receive care

within the community and engage in self-management activities of their health-care.

X. Plan transitions between various settings of care and providers.

4.3. Organizational perspective

Swan et al., (2019) claims that over the past years there has been investment in care coordination

thus allowing increment in care coordination service such as ACOs and PCMHs. Organizations

such as Centers for Medicare and Medicaid Services have invested in different programs such as

Comprehensive Primary Care. Although in each of the implemented program RNs have played a

critical role of becoming the common or integral personnel of the collaborative team.

5. Barriers and solutions to care coordination

5.1. Barriers

Uniformity

Although different health care providers continue to adopt coordinated care initiatives

there exists challenges such as lack of uniformity in coordinated care. Bean, (2017) claims that

most hospitals are their initial stages of implementing the program therefore making it hard for

some health care providers apply the value-based approach. Furthermore, EHRS interoperability

has also challenged the process (Swan et al., 2019).

Conflicts

Work conflict also affects the program implementation since the physicians might be in

position of talking to each other.

Cost

Cost of training RNs and RNs performing care coordination has hindered the

implementation process.

Knowledge

Lack of knowledge regrading care coordination and outcome measurement continues to

become a barrier for the implementation process.

5.2. Solutions

Bean, (2017) utilizes Dr. Botsford advice for health care systems looking to develop

proactive transition programs to begin with applying technology to facilitate making informed

decisions, establish multi-disciplinary teams and building high-quality post-acute care networks.

The Doctor continues to claim that providing a comparison platform of how skilled nursing

facilities were doing and providing a feedback regarding discharged patients provided critical

information that led to continuous performance improvement. It also provided professional

satisfaction of knowing that their patients are being cared for in a high-quality performance.

Such results can encourage workers to collaborate therefore reduce any existing conflict or

eliminate any possible barrier to care coordination. According to Swan et al., (2019) RNs should

be equipped with self-care management practices that allows them to share with their patients

therefore allowing early detection of some condition and improved personal outcomes.
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References

Bean, M. (2017). The importance of care coordination in a value-based world: Best practice

approaches from spectrum health. Becker's Hospital Review - Healthcare News.

https://www.beckershospitalreview.com/quality/the-importance-of-care-coordination-in-a-

value-based-world-lessons-learned-by-spectrum-health.html

NEJM Catalyst. (2018, January 1). What is care coordination? NEJM Catalyst - Practical

Innovations in Health Care Delivery. https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0291

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.