Knowing the answer to these questions allows for the development of a more individualized, holistic plan of care that can begin at the moment and subsequently be coordinated and managed across the continuum by RNs and other providers no matter the care continuum setting. Whether looking to stay well or recover from acute illness or live well with chronic illness, there are few community-based programs that meet one's rehabilitation and wellness needs.
Nursing and other healthcare professionals such as therapists and social workers are well positioned to lead entrepreneurial ventures that partner with community centers YMCAs, adult day care, housing, etc. Another necessary characteristic of the transformed healthcare system must be an unwavering focus on the patient. Patient- and family-centered care , rather than provider-centric care, is essential if patients and families are to assume responsibility for self-management.
The IOM defines patient-centered care as:. Health care that establishes a partnership among practitioners, patients, and their families when appropriate to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.
Practicing from a patient-centered approach means acknowledging that patients, not providers, know themselves best and realizing that quality care can only be achieved when we integrate patients and families into decision making and care and focus on what is important to patients.
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Without this, we will never deliver value. It helps define patient-reported outcomes or outcomes of medical care that are defined by the patient directly. Engaging the patient in shared decision making and shared care planning with patient-reported outcomes at the center of the plan of care is essential for patient activation in self-management. With patient-reported outcomes in mind, nurses can partner with patients in providing client education and coaching to strengthen the patient's capacity toward goal achievement. Use of motivational interviewing and action planning as a strategy to assist patients with behavioral change is a needed skill.
With action plans and goals at the forefront, the nurse provides ongoing information on treatment plans, provides coaching and counseling to build self-confidence in relation to new behaviors, coordinates reminders for preventive and follow-up care, and ensures that handoffs provide the next set of providers with needed information to continue the plan of care and avoid duplicative ordering. An integrated care continuum is posited to be a key strategy for achieving the triple aim—better quality, better service, and lower costs per unit of service.
But what is the continuum and what is the role of the nurse in care coordination across the continuum? The continuum of care concept was proposed in and was conceptualized as a patient-centered system that guides and follows individuals over time potentially from birth to end of life through a comprehensive array of seamless health, mental health, and social services spanning all levels and intensity of care Evashwick, The World Health Organization , p.
As the continuum consists of services from wellness to illness, from birth to death, and from a variety of organizations, providers, and services, ongoing coordination to prevent or minimize fragmentation is critical. All patients need care coordination as it serves as a bridge—making the fragmented health system become coherent and manageable—an asset for both the patient and the provider. For some patients, a more intensive form of care coordination is needed and may be assigned a care manager to oversee their condition and changing care needs during the different trajectories of their chronic illness.
Others may require a time-limited set of care and coordination services to ensure care continuity across different sites or levels of care. This care, referred to as transitional care, has been a major focus, as it has been validated that transitions represent high-risk periods for safety issues and negative outcomes because of lack of continuity of care Enderlin et al. To contend with these issues, the ACA set goals to reduce fragmentation of care.
Numerous transitional care models such as Naylor's Transitional Care Model, Coleman's Care Transitions Program, and Project Re-engineered Discharge have demonstrated efficacy in reducing readmissions, reducing visits to the ED, improving safety, and improving patient satisfaction and outcomes ANA, ; Enderlin et al. Care coordination is not something that is delegated to one individual or unique to an individual who may hold the title of care coordinator or navigator.
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All nurses, no matter what their role, must prioritize care coordination. With this in mind, all nurses should move away from the notion of discharging patients, which implies that their responsibilities for care are finished. In contrast, nurses should provide care with a mind to transitioning the patient to the next level or stage.
Transitioning implies a joint responsibility for care coordination over time. It is often the nurse at the point of care who has formed a relationship with the patient and learned important aspects of the patient's social context, challenges in managing the patient's health, and the patient's priorities of care. This information is invaluable and must be integrated into the plan of care for the patient across the continuum of care. For those with more complex care needs, especially those with multiple chronic illnesses, there is a need for a specialized role to ensure that care is coordinated across the continuum.
Care coordinator roles grounded in acute care or primary and ambulatory case or care managers, population health managers, patient navigators, healthcare coaches, transition coaches may be held by individuals with different professional and nonprofessional roles. Nurses have both the clinical and management knowledge and skill set needed to assume key coordination roles.
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Strong clinical knowledge grounded in the evidence is a priority characteristic for the care coordinator as this individual must be able to select and implement care processes and systems reflecting best practices, implement rapid-cycle improvements in response to clinical data, and track and analyze trends.
Lack of this requisite clinical knowledge will impede implementation of best practices and potentially impede strong interprofessional collaboration and communication that must be exquisite within a well-coordinated delivery system. Nurses have this unique clinical knowledge, making them ideal for navigating care across the continuum. We can only improve the care and health of populations if we truly understand the care we deliver. Understanding the care requires data. Nurses in the transformed healthcare system will need to be able to gather data and track clinical and financial data over time and across settings.
Tracking of key metrics treatments, health status, functionality, quality of life must occur at the individual and population levels. This gives needed information to understand the particular issues the individual patient is facing. Improving care at the individual level requires consideration of information on the population from which the individual is drawn.
The first step in understanding populations is to have a much deeper understanding of the patient population in order to drive better outcomes. To achieve the triple aim, it will be essential that we track outcomes over time related to psychosocial status, behavior change, clinical and health status, satisfaction, quality of life, productivity, and cost.
These data are used in predictive modeling to stratify the population according to disease state or risk profile. This information can then be used to engage patients in timely, proactive, tailored manner based on their needs. Using stratification, those at no or low risk will be recipients of health promotion and wellness and care.
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Those at moderate risk will require more intensive interventions, ranging from health risk management to care coordination and advocacy. Those who are at high risk and are high utilizers require further disease or case management services Care Continuum Alliance, ; Verhaegh et al. These data are used at the individual level to align the type of care with the patient need and at the organizational level to focus resources on segments of the population at greatest need.
Outcome data are one piece of the information needed for improvement. With outcomes in mind, one needs to examine what can be done to improve outcomes related to the experience, efficiency, or effectiveness of care. Use of shadowing as a technique to examine the real-time care experience provides valuable data on process flow, patient experience, and team communication. Combining shadowing data with Lean Six Sigma methodology or with rapid-cycle improvement processes is an approach for ongoing quality improvement that must be integrated into role expectations of the professional care team.
This is not an independent effort. In today's practice environment, interprofessional learning collaboratives targeting specific populations i. These collaborative groups as organized through quality departments, local hospital associations, the Institute of Health Innovation, and professional medical and nursing associations use benchmark data, shared either from their own facilities or from registries i.
This is complemented by discussions and sharing around best practices and system approaches to improvement that can be implemented in rapid improvement cycles at the point of care where the interprofessional team collaborates on an identified problem, process issue, or care gap, looking together for what is best for the patient. There is no doubt that nurses are poised to assume roles to advance health, improve care, and increase value.
However, it will require new ways of thinking and practicing. Shifting your practice from a focus on the disease episode of care to promoting health and care across the continuum is essential. Truly partnering with patients and their families to understand their social context and engage them in care strategies to meet patient-defined outcomes is essential. Gaining greater awareness of resources across the continuum and within the community is needed so that patients can be connected with the care and support needed for maximal wellness.
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Tracking outcomes as a measure of effectiveness and leading and participating in ongoing improvement to ensure excellence will require exquisite teamwork as excellence crosses departments, roles, and responsibilities. For 28 additional continuing nursing education activities on health care reform, go to nursingcenter.
Challenges in health and health care for Australia
Your Name: optional. Your Email:. Colleague's Email:. Separate multiple e-mails with a ;. Thought you might appreciate this item s I saw at Orthopaedic Nursing. Send a copy to your email. Some error has occurred while processing your request. Please try after some time. Salmond, Susan W. The authors have no conflict of interest to declare. Back to Top Article Outline. Table 1.