Care coordination: Identifying and connecting the most appropriate care to the patients

Abstract

Although nurses are increasingly expected to fulfill the role of care coordinator, the knowledge and skills required to be an effective care coordinator are not well understood. The purpose of this study was to describe the knowledge and skills required in care coordination practice using an interpretive phenomenological approach. Fifteen care coordinators from 10 programs were interviewed over a 6-month period. Semi-structured face-to-face interviews were audio recorded, transcribed, and analyzed using interpretive phenomenology. The central theme of care coordination practice was bridging the patient and the healthcare systems. To bridge, care coordinators needed to have knowledge of the patient and healthcare system as well as the skills to identify and negotiate treatments appropriate for the patient. The most salient finding and new to this literature was that care coordinators who used their medical knowledge about available treatment options to discern and negotiate for the most appropriate care to the patient made differences in patient outcomes. Nurses with medical and healthcare system knowledge, combined with the skills to navigate and negotiate with others in an increasingly complex healthcare system, are well situated to be care coordinators and generate optimal outcomes. Further investigations of critical care coordinator competencies are needed to support nurses currently enacting the role of care coordinator and to prepare future nurses to fulfill the role.

The Patient-Centered Medical Home: Mental Health and Parenting Stress in Mothers of Children With Autism

“…Care coordinators embedded within a practice is another potential method to improve care coordination. 26,27 Future research is needed to assess the impact of implementing care coordinators embedded within a practice and models like SYNAPSE on care coordination in families of children with ASD.…”

Nursing Care Coordination for Patients with Complex Needs in Primary Healthcare: A Scoping Review

“…This is mainly in response to the target patient populations' vulnerability and sometimes functional decline [92], but also because it allows nurses to gain more insight into the patient's living environment, including safety issues [33,48] and caregiver burden [93], which are crucial to care planning. Nevertheless, home visits should not be regarded as an isolated activity, but rather as a feature of a comprehensive care coordination intervention whose first step is to know the patient and caregiver in order to identify what care or service they need [94].…”

Scaling-up an integrated care for patients with non-communicable diseases: An analysis of healthcare barriers and facilitators in Slovenia and Belgium

“…The care coordinator acts as a bridge between a patient and the healthcare system; therefore, he or she should have in-depth knowledge and skills to navigate the patient in the complex system. Some studies suggest that the coordinator should have medical knowledge and suggest that nurses should take on this role (22). Coordination of care at higher levels, which is not tailored to each patient individually, could also provide an answer to this question for a wider population.…”