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Care Coordination
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Table of 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
  • 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

About the Author

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.

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