Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.
Developing a Care Coordination Strategy
Your primary goal is to ensure a seamless, high-quality patient experience that prevents hospital visits and improves outcomes. This involves three key areas:
A. Patient Engagement and Education
Effective care coordination is driven by the patient, not just the provider.
Comprehensive Health Literacy Assessment: Start by determining the patient's actual understanding of their condition and treatment plan, not just their education level. Use plain, non-medical language when explaining their plan.
Teach-Back Method: After explaining a new medication or self-care task, ask the patient (or caregiver) to explain it back to you. This is the gold standard for confirming understanding and ensuring adherence.
Motivational Interviewing: Use a supportive, non-judgmental approach to help patients identify their own reasons and motivation for making a behavioral change (like diet or exercise).
B. Communication and Collaboration
Since your center lost its dedicated case managers, you are the central communication hub.
Establish a "Closed-Loop" Referral Process: Don't just give a patient a specialist's phone number. Call the specialist's office, schedule the appointment yourself, and then follow up to confirm the patient attended. "Closing the loop" ensures continuity of care.
Create a Standardized Patient Summary: Develop a simple, one-page summary to send to all external providers (PCP, specialist, home health). This should include the medication list, active problems, and specific care goals.
Sample Answer
That's a common, yet challenging, scenario in healthcare today—expanding a staff nurse's role to fill critical gaps left by budget cuts. Taking on care coordination is a significant but manageable task, leveraging your existing skills in patient assessment, education, and planning.
Here is a structured approach you can take to effectively transition into this expanded role and plan for the specific health concerns of your community residents.
1. Initial Assessment and Preparation
Before diving into individual patient plans, you need to