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Solidify the Nurse Leader's Role in Care Coordination

Analysis  |  By Jennifer Thew RN  
   April 12, 2016

Strategies to help nurse leaders better support care coordination and transition care management efforts include knowing the patient population, leveraging the value of technology, and engaging staff as well as patients.

For better or for worse, this, shall we say, "unique" primary election season has caused me to do some deep thinking. Not so much about the candidates or their platforms, but rather about our society and way of life.

Do we want to run the country like a business where finances, bottom lines, and budgets are what's important? Do we want to function as a community where all entities—government, schools, and citizens—have a personal investment in achieving shared goals and outcomes? Does it have to be "either/or? Can it be "both/and?"

I don't have the answers, but, lately, when I've been thinking about healthcare, I've been mulling over the same questions.

Healthcare leaders have been doing the same.

In February when I hosted the HealthLeaders Media roundtable, "How Informatics Can Reshape Healthcare," panelist Kevin Myers, senior client director at GE Healthcare, made the following point, "There are a number of stake holders that are involved…They all have to put a little skin in the game. It can't just be the health system that carries the entire burden of improving outcomes."

This concept of collaborating across the care continuum to achieve mutual goals was discussed last month at the American Organization of Nurse Executives 2016 annual conference in Fort Worth TX. It came up during the concurrent session, "The Nurse Leader's Role in Care Coordination and Transition Management." Four nurse leader-panelists outlined the specifics of a joint statement on care coordination and transition management between AONE and the American Academy of Ambulatory Care Nursing.

"We will look at it not from the perspective of how do you begin, or how do you implement care coordination and transition management but… from the role of the nurse leader," says Susan Paschke, former senior director ambulatory nursing at the Cleveland Clinic in Ohio.

"What do you need to know and how do you need to work in order to make sure that you can implement it in your organization?"

Because care coordination and transition management are so integral in today's healthcare system, the two organizations felt it wise to further clarify the nurse leader's role in these areas. Together they developed six strategies that acute and postacute care nurse leaders could apply to care coordination and transition care management.

Strategy 1: Know How Care is Coordinated in Your Setting

The beginning of understanding how care is coordinated in the acute or post-acute setting is to know your patient population, says Claire Zangerle, RN, MSN, MBA, president and chief executive officer of the Visiting Nurses Association of Ohio. "Determine the needs and requirements and resources of the particular population. It's going to be different for one group of patients than the other," she says.

She recommends using a "tracer" to simulate a patient's journey through the healthcare system to discover the organization's barriers and best practices.

Identifying and becoming familiar with organizational care transition models is essential, says Zangerle.

"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 [model]," she says.

"If there isn't a model in place, there are numerous resources to allow you to pull a model together that works for your organization."

Strategy 2: Know Who is Providing Care

Defining the roles and key job responsibilities of those providing transition care is important, Zangerle says. In their quest to improve transition care, many health systems have added formal care coordination and transition of care roles like transition coach, care coordinator, case manager, etc.

Unfortunately, these multiple roles have often left the patient confused about who does what.  "Focus on eliminating the redundancy in roles and insure they're well-defined so those within the team and those outside the team can understand," she says.


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Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.

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