- 1.Adopt clear definitions of care coordination and transitional care that are patient, family, caregiver, and population centered that can be used consistently among all stakeholders.
- 2.Implement payment models expeditiously for evidenced-based care coordination and transitional care services delivered at the community level by teams led by the best professional to coordinate the care, including nurses and other professionals as well as physicians.
- 3.Ensure replicability and sustainability of care coordination and transitional care models through improved performance analytics and workforce development:
- a.Expedite funding to develop, implement, and evaluate performance measures that address gaps in effective and efficient care coordination and transitional care.
- b.Invest in workforce development to better prepare all team members to deliver effective and efficient care coordination and transitional care services.
Models that Work
- •Programs to enable frail elders to remain in their communities, preserve function, decrease hospitalizations and emergency department visits, improve other clinical outcomes, and contain costs below that of nursing homes.
- •The Nurse-Family Partnership model providing care coordination for impoverished, high-risk, first-time pregnant women has documented effective short-term and long-term outcomes for both mothers and babies through rigorous comparative evaluations (Olds et al., 2010).
- •The primary care–based nurse-managed health clinic model, defined in the Affordable Care Act, has strong care coordination practice as its hallmark.
- •Transitional care approaches to reduce avoidable emergent care and rehospitalization (Coleman et al., 2006;Naylor et al., 1999;Naylor et al., 2004;Naylor et al., 2009;Naylor et al., 2011;
High-value transitional care: translation of research into practice.Journal of Evaluation in Clinical Practice. 2011; https://doi.org/10.1111/j.1365–2753.2011.01659.xParrish et al., 2009).
- Naylor M.D.
- Bowles K.H.
- McCauley K.M.
- Maccoy M.C.
- Maislin G.
- Pauly M.V.
- Krakauer R.
- •Models are patient and family caregiver–centered in concept and design that support shared decision-making.
- •Interprofessional teams match services to patient and family needs to gain the highest value.
- •Team leadership shifts according to patient and family needs, preferences, and expertise of team members.
- •Existing and new payment mechanisms recognize evidence-based models led by any discipline that are associated with improved quality outcomes and cost reduction.
- •Explicit and seamless links connect patients, providers, and caregivers to community resources.
- •Teams have high reliance on the expertise, skills, and services of registered nurses.
- •Care coordination and transitional care provide seamless transition experiences for patients and family caregivers.
- •Ongoing quality measurement and comparative effectiveness research are needed to test these assumptions and define best practices.
- 1.Clear definitions of care coordination and transitional care:
- ▪Definitions should be patient, family, and population centric.
- ▪Definitions should address services provided by any qualified professional1based on the risk status and needs of the patient, family, or population.“Qualified professional” is defined as a health care professional who is educated and trained to coordinate the care of people at varying levels of risk. Although some professionals may be skilled at coordinating care for high-risk patients, others may qualify for managing only low-risk patients. Determining who is “qualified” should reflect the specific needs and health problems of the patient and family.1“Qualified professional” is defined as a health care professional who is educated and trained to coordinate the care of people at varying levels of risk. Although some professionals may be skilled at coordinating care for high-risk patients, others may qualify for managing only low-risk patients. Determining who is “qualified” should reflect the specific needs and health problems of the patient and family.
- ▪Definitions should be easily used and understood by the public, providers, and payers.
- 2.New payment and delivery models that recognize and incentivize teamwork:
- ▪Recognize and pay for models that provide effective organization and management of care across providers and settings.
- ▪Models must rely on effective communication and timely teamwork.
- ▪Models, although team-oriented, typically highlight the central role of registered nurses.
- 3.Replicability and sustainability of care coordination and transitional care models through improved performance analytics and workforce development:
- ▪Invest in research linking care coordination interventions to quality and cost outcomes with urgency to show the impact on complications and readmissions.
- ▪Invest in workforce capacity–building and ongoing development.
- ▪Move beyond existing care coordination performance measures that are largely provider centered and condition specific.
- ▪Create new shared accountability composite measures targeting process and outcomes that extend beyond minimalist checklists to address changing risk and patient complexity. The following key measures are recommended to be included.
Care Coordination: Priorities for Measurement
- •The need for examination of measure denominators and risk adjustment strategies that capture differences in care coordination and transitional care intensity across patient populations.
- •The need for a common denominator to identify the general population for care coordination and transitional care across settings moving beyond diagnosis and condition-specific denominators.
Patient and Family Experience of Care Coordination
- •Measures that address timeliness and responsiveness of care and services.
- •Measures that capture patient and family goals and preferences for care and services.
- •Measures that consider unique care coordination and transitional care needs of children and their families.
- •Measures that consider the extent to which care coordination and transitional care are culturally appropriate.
Process Measures of Care Coordination
- •Measures of the development, implementation, and regular review of an integrated plan of care incorporating patient and family preferences and goals.
- •Measures of timely and accurate communication of the plan of care across providers and settings.
Outcome Measures of Care Coordination
- •Standardized measures of preventable hospitalizations and emergency department visits.
- •Measures of patient and family satisfaction with care coordination and transitional care.
- •Measures of quality of life and functional status across the continuum of care.
- •Measures of staff and team competence in care coordination, particularly competence in complex care coordination and transitional care for seriously ill patients and their families.
- •Measures addressing access to appropriate and competent care coordination and transitional care.
Innovative Models of Care
- •The Nurse-Family Partnership model
- •The Eleventh Street Family Health Service
- •Family Practice and Counseling Network
- •Transitional Care Model (TCM) at the University of Pennsylvania School of Nursing (Naylor et al., 1999;Naylor et al., 2004;Naylor et al., 2009;
- •The Rush Enhanced Discharge Planning Project (
- •The Care Transition Program at the University of Colorado (Coleman et al., 2006) uses registered nurses, social workers, or community workers as transition coaches to promote self-management and greater family involvement to bridge transitions between hospital and community settings. “Care Transition Intervention” emphasizes medication self-management, patient-centered health records, appointment scheduling, and recognizing indicators of deteriorating condition.
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Task Force members: Maureen Dailey, DNSc, RN, CWOCN; Tine Hansen-Turton, JD, MGA, FAAN; Harriet Kitzman, PhD, RN, FAAN; Gerri Lamb, PhD, RN, FAAN; Mary Naylor, PhD, RN, FAAN, and Sue Reinhard, PhD, RN, FAAN.