Solidify the Nurse Leader's Role in Care Coordination

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.

Strategy 3: Establish Relationships that Will Support Care Coordination

Looking beyond the inside of an organization is a hallmark of good care coordination and transition care, says Beth Ann Swan, CRNP, PhD, FAAN, dean and professor Jefferson School of Nursing, Thomas Jefferson University in Philadelphia.

"Our organization has had a history of strong academic-practice partnership," she says.

The SON worked with Thomas Jefferson University Hospitals to develop the Communication Catalyst Program to provide better care transition experiences for patients by improving nurse-patient communication. The program is educating 300 nurses in the care coordination and transition management core curriculum.

It covers 12 topics including advocacy, education and engagement of patients and families, coaching and counseling of patients and families, patient-centered care planning, support for self-management, and teamwork and collaboration.

"The Communication Catalyst program enables and empowers nurses to deliver better care through the use of effective communication, emphasizing the use of empathy and developing a sense of partnership between clinical teams and patients," Swan says.

Strategy 4: Understand the Value of Technology

"As a nurse leader I really need to understand what's happening in my organization," says Mary Beth Kingston, RN, MSN, NEA-BC, system chief nursing officer at Milwaukee-based Aurora Health Care.

That's "because I'm often in the role of advocating, of translating and integrating, and decision-making regarding care coordination technology."

Kingston recommends that nurse leaders assess their organization's current technology to see how it affects care coordination and transition management, that they strategize and optimize technology, and that they collaborate with IT on data analytics.

Strategy 5: Engage the Patient and Family

Patients as passive participants in their care is becoming a thing of the past, Paschke says. "We want them to take an active role and be an active partner," she says. "So again, they need that knowledge and skill and to be able to develop that confidence to be able to manage their healthcare issues."

Rather than a paternalistic model where healthcare provides tell patients what to do, patients are now becoming participants who discuss their goals with their providers.  "Nurses now are empowered to lead that healthcare team in engaging patients and families," says Paschke.

Strategy 6: Engage All Team Members in Care Coordination

The care team has grown beyond just the nurse/patient or physician/patient relationship, Paschke says. Anyone who has an impact on how patients manage their care—family members, pharmacists, nutritionists, community resources—should be engaged in the patient's care.

"One of the ways [to do this] is to identify stakeholder champions," she says. "Who are the people who are going to be specifically interested so that they can help you to champion your efforts?"

Collecting metrics that show the effectiveness of care coordination and transition management helps strengthen team member's engagement. This, in turn, heightens patient empowerment, staff and provider satisfaction, and enhances clinical quality and safety outcomes, Paschke says.