The Nurse’s Role in Care Coordination

This is the transcript for the Vila Health: The Nurse’s Role in Care Coordination . You can get information here.

Introduction

Care coordination is one of the fastest growing and evolving trends in the nursing field. In order to be an effective care coordinator, it is important to understand the roles that case managers and other care coordination team members play in a health care setting. It is also valuable to understand how these roles have evolved—and continue to evolve— over time. In this activity, you will learn more about the role of care coordination in an acute care setting.

After completing the activity, you will be prepared to:

· Summarize the roles that case managers and other team members play in care coordination.

· Contextualize care coordination and today’s care coordination trends historically.

Details

Congratulations! You have been just hired as a case management intern in the Care Coordination Department at St. Anthony Medical Center. Located in Minneapolis, St. Anthony is a 120-bed hospital in the Vila Health system, which operates facilities in several Midwest states. The Care Coordination Department manages patient cases throughout the entire hospital.

Since it’s your first day, your first task is to get oriented. Your preceptor will help you get started. To learn more about the roles that care coordinators play in nursing, you’ll be talking with experienced case managers, social workers, and other members of the team. You’ll also sit in on a coordination planning meeting.

Office

It looks like you have an email from Denise McGladrey, your new preceptor. Click the icon to read it.

From: Denise McGladrey Subject: Your first day

Welcome to St. Anthony! We’re so glad to have you on the Care Coordination team. As you know, I am going to be your preceptor. My job is to help you transition into your new role as case management intern and to offer you support. You should feel free to come to me with questions.

I have several meetings today, so I won’t be able to meet with you until this afternoon. In the meantime, since this is your first day, I want you to learn more about your role by talking with some of the people with whom you’ll be collaborating. I’d like for you to ask them questions about the case management role and the skills you’ll need to be successful. Most of the people you’ll be talking to have a good deal of experience, so I’d also like for you to ask questions about how the field has evolved over the years.

I’ve gone ahead and scheduled two interviews with you: one with Vicki Vasquez, who, as you know, is the Director of Case Management here at SAMC. The other interview will be with Samantha Rockwell, an experienced social worker who you’ll be coordinating with quite a bit in the near future. You’ll also have the opportunity to schedule interviews with your choice of a number of other team members.

I’ll be catching up with you later. Have a great day!

—Denise

Schedule Interviews

It looks like you need to speak with Mackenzie, Crystal, and Joyce about this incident—and then find some strategies for motivating them to succeed. You should go talk with each of them now.

Seth Patterson

Case Manager

Can you please describe your role in the department?

Seth: I coordinate care for all kinds of people in the hospital. They tend to give me cases involving older adults, since that’s my background, but for the most part all the case managers need to be equipped to work with all kinds of cases. I worked with geriatric patients almost exclusively with another hospital. Other case managers come to me sometimes when they need geriatric resources or have questions about how to help elderly patients.

In your opinion, what are some of the most important things a new case manager needs to know?

Seth: Here’s a tip: make yourself a master list of phone numbers! I can help you get started with that. After a while, you figure out who to call at each insurance company when you really need to get something done, or who to call at various social service agencies to get accurate information about resources, and so forth. I can’t even tell you how much time my list saves me!

What are some of the biggest mistakes case managers make?

Seth: One of the biggest problems case managers have is with coordinating transfers from one facility to another—especially when you’re talking about older adults, because moving them can be very risky. When patients go to the wrong facilities, that can be traumatic for the patient and costly for the hospital. It’s important to do your research and find the best possible facilities for patients so they don’t have to be moved again. That can be a real challenge because of insurance issues… ugh! It’s incredibly frustrating when the best facility for someone isn’t covered by insurance. But that’s just part of our jobs…. negotiating stuff like that with insurance companies on behalf of our patients’ best interests. It’s also really important to figure out whether sending somebody home is a good idea. Sometimes home health care is the best solution, but sometimes it’s not, depending on the family situation and all kinds of factors you need to consider.

In your experience, how has care coordination changed?

Seth: Dealing with insurance companies and Medicare and federal regulations and all of that… it just gets more complicated all the time. I like to think that I’m an advocate for our patients, helping them navigate through all this red tape and regulation. If it’s this hard for me to navigate things, I can only imagine how hard it is for the patients—especially if they’re elderly or have language barriers and stuff like that.

What are the some of the most important trends in care coordination?

Seth: Electronic medical records are revolutionizing what we do. And overall this is a good thing. I mean, a big part of what we do is to try to prevent fragmentation of care, and EMRs make a world of difference with that. On the other hand, as someone who’s worked with elderly people, I know what a problem EMRs can pose to patients who aren’t technologically literate. I’ve heard and seen horror stories. One of the nurses at a clinic where I used to work, she told me about this elderly woman who had elevated blood sugar levels. Her manager wouldn’t let her call the woman to get a retest because the clinic wanted to push people into using the new patient portal. You know, because of meaningful use issues? If enough people didn’t use the portal, the clinic could lose funding. Well, this woman was in her 80s, and lo and behold, she never looked at her electronic record and wound up at the hospital with a blood sugar level over 600!

Nora Jackson-Green

Case Manager

Can you please describe your role in the department?

Nora: Oh boy, where do I even get started? I don’t want to sound melodramatic, but sometimes I feel like I’m a human life raft. The medical system is this massive sea of confusing information. And sometimes there’s dangerous sea monsters who are more interested in getting paid than helping a patient get to land. My job is to navigate the patients through all this choppy water so they don’t drown.

In your opinion, what are some of the most important things a new case manager needs to know?

Nora: Case managers need to know how to communicate with the patients and their families! They need to make sure that families truly have the resources they need to help care for a patient. It’s not enough to ask patients what they need, because a lot of times they don’t know what they need. Or they totally underestimate how much physical and emotional work goes into caring for a loved one. It’s our job to anticipate their needs before a crisis happens. And as Baby Boomers like me get older, it’s going to be more and more important to know how to help families navigate these kinds of situations. We’re not a society that’s set up to help people who are old and sick! So it’s up to us to make sure people get what they need.

What are some of the biggest mistakes case managers make?

Nora: Case managers really need to be on the lookout for red flags that something’s wrong, or that something’s not going to go smoothly. Because otherwise, patients who really need our help can fall through the cracks. We don’t always have a lot of time with the patients, so we need to pay attention to all kinds of details. If a patient is showing any possible signs of dementia, for example, that’s a red flag. We need to investigate further. If a patient is taking a potentially dangerous drug, or if they show signs of prescription drug dependency, we need to follow up and not just send that patient home. It’s kind of like being a detective, only you don’t know exactly what you’re looking for.

In your experience, how has care coordination changed?

Nora: Well, I think the whole health care system has changed in that there’s so much more emphasis on accountability. We have to prove we’re doing a good job. Care coordination has evolved with the emphasis on outcomes and quality. It used to be that care coordination was a more unofficial part of what nurses did. Now, it’s being recognized more and more as a critical job duty, and that’s because coordinated care leads to better outcomes.

What are the some of the most important trends in care coordination?

Nora: Like I said, the emphasis on outcomes and quality has really changed care coordination. We’re constantly being evaluated on patient outcomes. There are direct financial consequences for the hospital if our outcomes aren’t good. That means that care coordination is taken more seriously, because it absolutely has to be.

Vicki Vasquez

Director of Case Management

Can you please describe your role in the department?

Vicki: Well, the part of my job that I like the most is serving as a role model and mentor to the team members in this department. I’ve worked in care coordination for a long time. So if someone feels like they’re up against a brick wall and can’t figure out how to help a patient, I can put on my coach hat. I enjoy that. A more challenging part of my job is working with the bureaucracy to make sure that patients get what they need and that the hospital gets paid. Health care law and regulations change all the time. You’ll be shocked at how much they change. As the leader of this department I have to make sure I’m 100% on top of these changes—especially since St. Anthony is an Accountable Care Organization. The hospital is constantly evaluated on 33 quality indicators, and our ability to manage complicated cases is essential if we’re going to keep our rank up.

In your opinion, what are some of the most important things a new case manager needs to know?

Vicki: There’s a lot you need to know to be an effective case manager. One of the most crucial skills is problem solving. If you’re looking for a job where there are clear-cut answers in a guidebook, well, maybe you should be an accountant or something. Every case is like a puzzle that needs a unique solution, and a lot of times, even the best solutions need troubleshooting.

And a big part of learning how to solve these problems is looking at patients holistically. You know what I mean by holistically, right? That means you have to look at the whole situation and understand how all the parts of the situation fit together. You have to look at the whole picture—health history, psychological factors, family situation, financial situation, ethnic and religious factors. There are all kinds of barriers to care you can miss if you don’t look at how the factors fit together.

What are some of the biggest mistakes case managers make?

Vicki: I think different case managers tend to make different mistakes. Like I said, it’s really important to understand patients holistically. When case managers focus exclusively on medical issues to the exclusion of a patient’s family or social situation, that’s a big miss. And another serious error that case managers can make is exceeding their scope of practice. It’s very important not to overstep boundaries and make decisions that belong to physicians or other members of the team. And that’s an easy trap to fall into… like, for example, it can be very tempting to make a decision about changing a patient’s medication or dosage without consulting the primary physician. Maybe the physician is hard to reach that day, and maybe it seems very obvious to the case manager that a medication needs to be discontinued. But those kinds of decisions can lead to critical errors and liability issues. Case managers absolutely need to respect the primary physician’s role as the team lead. And sometimes, like it or not, they need to follow orders.

In your experience, how has care coordination changed?

Vicki: We’re starting to understand care coordination as a specialized job duty in a way that we didn’t before. There’s always been care coordination. Nurses did that as a part of their jobs, and they still do. But now we have full time case managers, and schools are offering coursework and formal training in care coordination.

What are the some of the most important trends in care coordination?

Vicki: Well, the health care system as a whole has gone through some major paradigm shifts. From the perspective of our work, I think the most important trend has to do with value-based payments. The hospital’s ability to receive reimbursement is directly tied to quality and patient outcomes—especially since we’re an Accountable Care Organization. Because of this, care coordination professionals play a crucial role in overseeing care to prevent errors. And overall, this is a positive change that improves patient care. But it does add a new level of pressure on case managers.

Samantha Rockwell

Social Worker

Can you please describe your role in the department?

Samantha: I consult with case managers to make sure that they’re considering all the social issues that impact a patient’s ability to get the care they need and to manage their care. I meet with patients and find out what’s going on in their lives… their financial situations, their family situations, possible barriers to care, anything really that might impact their ability to get care. I also work with case managers to help locate appropriate resources for clients

In your opinion, what are some of the most important things a new case manager needs to know?

Samantha: Case managers need to remember that care coordination is a transdisciplinary field. You have to be able to collaborate effectively with an interdisciplinary team. In fact, I would say that collaboration is possibly the most important skill that a case manager needs. You work with all kinds of people both inside and outside the hospital, and with insurance companies and families too. Nobody expects case managers to have all the answers, but they need to know who to work with and how to work with people to get these answers.

What are some of the biggest mistakes case managers make?

Samantha: When case managers overlook barriers to care, that’s a big problem. Sometimes case managers have blind spots when it comes to identifying these barriers. A few years ago, I worked with a case manager that just didn’t seem to understand transportation barriers. She would set up follow up care for patients way out in the suburbs. But a lot of our patients, they rely on public transit and can’t get out that far. Or they’re old and they don’t drive, or they don’t feel comfortable driving on freeways to new places. I don’t know why it never occurred to her that this could be a problem.

In your experience, how has care coordination changed?

Samantha: There’s a lot more awareness of the importance of looking at patients’ needs as they relate to sociological issues. This kind of awareness has been around informally for a long time—I mean, nurses have always been aware of these kinds of issues, and social workers have been employed by hospitals for a long time. But now social workers are being brought in more routinely to assess situations, as opposed to bringing us in later after something goes wrong. There are a lot of opportunities for social workers to go into care coordination right now, and that’s exciting.

What are the some of the most important trends in care coordination?

Samantha: Thanks to the Affordable Care Act, most people have access to medical care now. We used to see a lot of uninsured patients in the hospital, and now uninsured patients are the exception. This is a good change, of course—a very good change. But it also brings challenges. We’re working with people now who have little or no experience with the health care system. They need to be educated on how to work effectively with us. A lot of people don’t realize how things like deductibles work, and that health insurance doesn’t cover every single expense. And the Affordable Care Act also has led to more people in the system from lower socioeconomic groups. These people tend to have more barriers to care. We have to anticipate that some people will need more guidance through the system than others.

Lucas Branch

Diabetes Educator

Can you please describe your role in the department?

Lucas: I work with case managers to make sure that patients get the information they need about diabetes care and prevention. When appropriate, I provide patients with resources to help them manage their diabetes. Often I help patients who are diagnosed with a chronic condition and who also have diabetes, since that new condition might mean they have to make changes in their diabetes management plan. I also talk with patients who have prediabetes or risk factors.

In your opinion, what are some of the most important things a new case manager needs to know?

Lucas: From my perspective, case managers need to be aware that it’s critical to provide patients with accurate information—and explain to them how to use it. With diabetes, there’s so much misinformation out there. Some patients underestimate the danger of diabetes and think it’s no big deal. Others are completely terrified and think it’s a death sentence, and they don’t realize they have the power to manage it. And that’s true of other medical conditions as well. People rely way too much on Dr. Internet to get the information they need. A case manager needs to make sure that patients have real information they can use.

What are some of the biggest mistakes case managers make?

Lucas: As a team, it’s so important to do everything we can to prevent fragmentation of care. Fragmentation brings costs up and quality down, and it can be really dangerous. We need to make sure patients aren’t getting conflicting information or medication from different providers.

In your experience, how has care coordination changed?

Lucas: That’s a better question for someone like Nora, who’s been working in this field for so much longer than me! But even in the short time I’ve been here, I can see how much more care goes into managing patient transfers. We do a lot more investigating now to make sure patients are going to the right facilities.

What are the some of the most important trends in care coordination?

Lucas: The team mentality has made a really big difference. The idea that you bring in a diabetes educator, you bring in a dieti

Complete an interactive simulation of the role of the nurse in health care coordination. Then, create a comprehensive patient needs assessment of 4-5 pages based on that simulation.

Introduction

Note: Each assessment in this course builds on your work from preceding assessments; therefore, complete the assessments in the order in which they are presented.

Care coordination is an emerging and complex field in the health care system because of the growing number of providers, the various settings of care, and the numerous methods of delivering care. Hospitals are implementing several interventions to address gaps in care coordination, such as enhanced systems of communication, information technology, and personnel resourcing. This assessment provides an opportunity for you to complete a comprehensive needs assessment.

In the 2000 report To Err Is Human: Building a Safer Health System, the Institute of Medicine identified collaborative communication and the reduction of medical errors as top priorities to improve the quality and safety of patient care. In response to this, the National Quality Forum (NQF), a nonprofit organization that works to catalyze improvements in health care, identified care coordination as an important national strategy to improve patient safety and quality of care delivery.

Coordination of care supports patient safety and quality and is a recognized professional standard shared by registered nurses regardless of their practice settings. Whether educating a patient about his or her medication and plan of care or reviewing follow-up care, nurses are essential in facilitating the continuity of care for all patients. Historically, nurses have engaged in coordinating care for every one of their patients. As the landscape of health care evolves, so does care coordination.

Reference

Institute of Medicine. (2000). To err is human: Building a safer health system. National Academies Press.

Note: Complete the assessments in this course in the order in which they are presented.

Preparation

As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.

· What are the key reasons for completing a patient needs assessment?

· Which types of information are likely to be most valuable for improving patient outcomes?

· What are the benefits of a multidisciplinary approach to coordinated care?

To prepare for this assessment, complete the following simulation:

· Vila Health: The Nurse’s Role in Care Coordination .

This simulation explores the roles that case managers and other team members play in care coordination. Upon completion of the exercise, you should have a better understanding of care coordination trends and their historical contexts. Use the information available in this simulation to begin your assessment of the patient, Mr. Decker.

Note: Remember that you can submit all or a portion of your draft to Smarthinking for feedback before you submit the final version of this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.

Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:

· Assessment 1 Example [PDF] .

Requirements

Complete a comprehensive needs assessment for Mr. Decker, based on the information provided in the Vila Health simulation and your own research.

Comprehensive Needs Assessment Format and Length

Format your comprehensive needs assessment using APA style:

· Use the  APA Style Paper Tutorial [DOCX]  provided. Be sure to include:

. A title page and references page. An abstract is not required.

. A running head on all pages.

. Appropriate section headings.

· Your needs assessment should be 4–5 pages in length, not including the title page and references page.

Supporting Evidence

Cite 3–5 sources of scholarly or professional evidence to support your assessment.

Conducting the Assessment

The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your needs assessment addresses each point, at a minimum. Read the Comprehensive Needs Assessment Scoring Guide to better understand how each criterion will be assessed.

· Identify current gaps in a patient’s care.

. Use an appropriate needs assessment tool to identify gaps. This tool may be one in use at your place of employment, one you locate for yourself, or one provided by faculty.

. Consider the types of patient information that will be most useful in assessing the current level of care.

· Develop a strategy for gathering additional necessary assessment data not readily available from an initial patient interview.

. Consider the full range of interrelated needs that affect the patient’s health.

· Discuss 3–5 societal, economic, and interprofessional factors most likely to affect patient outcomes.

. Consider the potential effects of these factors on outcomes.

. Support your conclusions with evidence.

· Relate specific patient and care coordination outcome measures to professional standards.

. Provide the rationale for measuring outcomes based on established agencies and organizations.

. Describe the relationship between specific outcomes and the identified standards.

· Identify evidence-based practices for successful implementation of care coordination.

. Use relevant and credible sources from the research literature.

. Consider best practices for a population-health focus on patient outcomes.

· Advocate for the benefits of a multidisciplinary approach to patient care.

. Provide the key points in your argument.

. Support your assertions with evidence.

· Write clearly and concisely, using correct grammar and mechanics.

. Express your main points and conclusions coherently.

. Proofread your writing to minimize errors that could distract readers and make it more difficult to focus on the substance of your needs assessment.

· Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.

Portfolio Prompt: You may choose to save your comprehensive needs assessment to your ePortfolio.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

· Competency 1: Develop patient assessments.

. Identify current gaps in a patient’s care.

. Develop a strategy for gathering additional necessary assessment data not readily available from an initial patient interview.

· Competency 2: Explain the effect of societal, economic, and interprofessional factors on patient outcomes and the care coordinator’s role.

. Discuss societal, economic, and interprofessional factors most likely to affect patient outcomes.

. Advocate for the benefits of a multidisciplinary approach to patient care.

· Competency 3: Evaluate care coordination plans and outcomes according to performance measures and professional standards.

. Relate specific patient and care coordination outcome measures to professional standards.

· Competency 4: Develop collaborative interventions that address the needs of diverse populations and varied settings.

. Identify evidence-based practices for successful implementation of care coordination.

· Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.

. Write clearly and concisely, using correct grammar and mechanics.

. Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.

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