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April 14, 2016

Six ways nurse leaders can spearhead care coordination

Daily Briefing

From surgeons to pharmacists, a wide variety of people are involved in patient care—and nurse leaders are in a unique position to connect stakeholders and coordinate their efforts, Jennifer Thew writes in Health Leaders Media.

"Because care coordination and transition management are so integral in today's health care system," Thew writes, it's important "to further clarify the nurse leader's role in these areas."

Thew shares six ways for nurse leaders to maximize their contributions across the care continuum.

1. Know how your patient goes through the health care system

An organization's patient population affects how care is coordinated. An acute care setting may have a different patient population than a rehab center or other post-acute provider—and that will affect the care coordination strategy.

Nurse leaders need to "determine the needs and requirements and resources of the particular population," says Claire Zangerle, president and CEO of the Visiting Nurses Association of Ohio.

One way to understand patients' needs is by tracing individual patients through the system. By simulating their care journey, nurse leaders can better understand where patients are meeting barriers—and how to overcome those obstacles.

"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]," says Zangerle.

2. Define team roles

As patients pass through the care system, workers need defined roles and responsibilities. Creating formal titles, such as care coordinator and transition coach, can help. But it's important, Thew says, to ensure each title is distinct to avoid confusing patients.

One challenge for coordinated care: Patients often go outside the network

"Focus on eliminating the redundancy in roles and [ensure] they're well-defined so those within the team and those outside the team can understand," Zangerle says.

3. Establish outside relationships

If nurse leaders know only what their own organization is doing, they can't learn from others' best practices.

At Thomas Jefferson University, the nursing school worked with the university hospital system to create a training program to educate nurses on improving care transitions and nurse-patient communication. About 300 nurses are currently enrolled.

4. Focus on tech

Nurse leaders are often tasked with recommending or implementing care coordination technology, says Mary Beth Kingston, CNO at Milwaukee-based Aurora Health Care.

Nurse leaders, she says, need to know the ins and outs of the current IT system and whether it's positively—or negatively—affecting care coordination and transition management. Once they fully understand how technology interacts with patient care, nurse leaders can talk to the IT team about ways to better utilize the systems.

5. Engage patients and their loved ones

Nurse leaders can help patients to "take an active role and be an active partner" in their care by arming patients with the knowledge and skills to manage their health, says Susan Paschke, former senior director of ambulatory nursing at Cleveland Clinic. "Nurses now are empowered to lead that health care team in engaging patients and families."

6. Include the entire team

The care management team has expanded beyond one nurse or one physician, Thew writes. There are many stakeholders, including the patient's family and community, and all should be engaged in the patient's care.

"One of the ways [to do this] is to identify stakeholder champions," says Paschke. "Who are the people who are going to be specifically interested so that they can help you to champion your efforts?" (Thew, Health Leaders Media, 4/12).

21 best practices to equip nurse leaders to deliver continuous, coordinated care

Health care providers face a mandate to provide seamless care across settings, but conventional approaches to cross-continuum care coordination often fall short.

This Nursing Executive Center study equips nurse leaders to address underlying, systemic issues that affect all transitions across the care continuum—and build a care delivery system that "never discharges" the patient.


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