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    Care Coordination: A Blueprint for Action for RNs: A Blueprint for Action for RNs
    Care Coordination: A Blueprint for Action for RNs: A Blueprint for Action for RNs
    Care Coordination: A Blueprint for Action for RNs: A Blueprint for Action for RNs
    Ebook217 pages1 hour

    Care Coordination: A Blueprint for Action for RNs: A Blueprint for Action for RNs

    By Gerri Lamb and Robin Newhouse

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    About this ebook

    In today’s health care environment, the drumbeat for care coordination grows louder and more urgent. It’s an effective way to improve quality and outcomes. Nurses are integral to this process, yet most feel their contributions are unrecognized and underappreciated. What can nurses do?

    Care Coordination: A Blueprint for Action for RNs helps today’s nurses reclaim this critical practice domain. It explores key issues in care coordination and offers timely, strategic actions nurses can take right now to identify opportunities and overcome barriers. It also includes critical resources for nurse care coordinators.

    This book will help you:

    Understand care coordination – past, present, and future – as well as the professional and practice environments in which it occurs
    Define the activities associated with effective care coordination
    Recognize the significant need for care coordination and opportunities for nurses
    Identify and explore issues pivotal to creating new inroads for nursing to adapt and advance this important work
    Expand the capacity of nurses to deliver care coordination and develop new and better care coordination models
    Learn how you and your fellow nurses can advance your important role in care coordination in the current and emerging health care environment
    Care Coordination A Blueprint for Action for RNs is the sequel to ANA's Care Coordination: the Game Changer How Nursing is Revolutionizing Quality Care. In Blueprint, authors Lamb and Newhouse take Game Changer's in-depth coverage of issues and impact of nurse care coordination and translate it into "practical, strategic and actionable" steps that all RNs can take right now to make a difference in this critical area of nursing practice.

    Nursing’s stellar history in care coordination demands a future role! Help move the dialogue forward. Order Care Coordination: A Blueprint for Action for RNs and Care Coordination: The Game Changer How Nursing is Revolutionizing Quality Care today!
    LanguageEnglish
    PublisherNursesbooks
    Release dateFeb 19, 2018
    ISBN9781558107052
    Care Coordination: A Blueprint for Action for RNs: A Blueprint for Action for RNs

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      Book preview

      Care Coordination - Gerri Lamb

      CareCoordination_FC_300RGB.jpg

      Care Coordination

      A Blueprint for Action for RNs

      Gerri Lamb, PhD, RN, FAAN
      Robin Newhouse, PhD, RN, NEA-BC, FAAN
      American Nurses Association
      Silver Spring, Maryland • 2018

      American Nurses Association

      8515 Georgia Avenue, Suite 400

      Silver Spring, MD 20910-3492

      1-800-274-4ANA

      http://www.NursingWorld.org

      The America Nurses Association (ANA) is the premier organization representing the interests of the nation’s 3.6 million registered nurses. ANA advances the nursing profession by fostering high standards of nursing practice, promoting a safe and ethical work environment, bolstering the health and wellness of nurses, and advocating on health care issues that affect nurses and the public. ANA is at the forefront of improving the quality of health care for all.

      The opinions in this book reflect those of the authors and do not necessarily reflect positions or policies of the American Nurses Association (ANA).

      © 2018 American Nurses Association. All rights reserved. Reproduction or transmission in any form is not permitted without written permission of the American Nurses Association (ANA). This publication may not be translated without written permission of ANA. For inquiries, or to report unauthorized use, email copyright@ana.org.

      Library of Congress Cataloging-in-Publication Data available on request.

      978-1-55810-703-8 print SAN: 851-3481 01/2018

      978-1-55810-704-5 ePDF

      978-1-55810-705-2 ePub

      978-1-55810-706-9 Kindle

      First published: January 2018.

      This book is dedicated to our editor Eric Wurzbacher, who shares our passion for care coordination and the nursing profession. We celebrate his many contributions as editor for ANA and are grateful and honored to have worked with him. We wish you wonderful new adventures in your retirement.
      We also dedicate Blueprint to all of our nurse colleagues who advance the professional practice of care coordination supporting and improving the lives of the people they serve. You inspire and remind us every day about the importance of nursing care to the health and well-being of our nation.

      Brief Contents

      About the Authors

      Part I: A Care Coordination Blueprint for 21st Century Nurse

      Chapter 1: An Action-Oriented Approach to Care Coordination for Today’s RNs

      Chapter 2: Care Coordination in Health Care Today: The Context and Framework for the Blueprint

      Part II: The Blueprint’s Six Action Issues

      Action Issue 1

      Action Issue 2

      Action Issue 3

      Action Issue 4

      Action Issue 5

      Action Issue 6

      Part III: Designing Your Own Blueprint for Action

      Index

      Contents

      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

      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

      About the Authors

      Gerri Lamb, PhD, RN, FAAN, is a well-known speaker and author on care coordination and case management. Her work as editor and lead author of ANA’s Care Coordination: The Game Changer resulted in one of the first books that explored the many facets of nurse care coordination in the context of the massive transformations of the U.S. health system. 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 book 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 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. Newhouse is a distinguished professor and dean of the Indiana University School of Nursing, and serves on the Methodology Committee of the Patient-Centered Outcomes Research Institute and the AcademyHealth Board. Writing this book with Gerri Lamb combines two of her favorite topics: evidence translation and measuring the effect of nursing processes on patient outcomes. Newhouse was inducted into the Sigma Theta Tau International Honor Society of Nursing Nurse Researcher Hall of Fame (2014) and is an elected member of the National Academy of Medicine (2017).

      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: A Blueprint for Action for RNs is intended as a short, succinct, and action-oriented guide for registered nurses (RNs) to examine and advance their important role in care coordination in the current and emerging health care environment. Our goal for preparing this guide is to assist RNs in distilling an ever-expanding body of literature, commentary, and policies on care coordination. We have attempted to focus attention on topics and strategies that we believe are essential to reducing barriers to and accelerating nurse care coordination practice.

      Care Coordination: Its Coming of Age

      Care coordination has a long and rich history in nursing and health care. The 2011 Institute of Medicine (IOM) report on the future of nursing identified care coordination as one of the traditional strengths of the nursing profession (p. 63). For decades, nurses have designed, implemented, and evaluated innovative programs using care coordination as the central process for helping patients and families access and integrate information and services.

      Nurse care coordination programs have contributed to significant improvements in the patient experience of health care, management of chronic illnesses, and reductions in costly hospital admissions and readmissions (Naylor et al., 2013). And while care coordination is appropriately viewed as an interprofessional activity requiring communication and integration of care among many providers, RNs and advanced practice RNs (APRNs) are commonly responsible for initiating, managing, and evaluating care coordination interventions.

      Over the years, attention to care coordination has increased or declined according to priorities and incentives in our health care system. In the 1970s, for example, when there was considerable focus on enabling vulnerable older adults to remain in their

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