The imperative for patient-, family-, and population-centered interprofessional approaches to care coordination and transitional care: A policy brief by the American Academy of Nursing’s Care Coordination Task Force

An integrative review of nurse‐led community‐based case management effectiveness

“…It is unknown whether this will change under the ACA. The American Academy of Nursing, which represents and advocates for nurses, recommends that the business community ‘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’ (Cipriano , p. 330). Thus, there is urgent need for financial support for evidence‐based care coordination.…”

Building workforce capacity for complex care coordination: a function analysis of workflow activity

“…Still, the service model does share similarities with international strategies and developments in care coordination models where non-physician providers are leading interprofessional team-based models to support care coordination in health systems [5]. Even so, differences in work functions according to context suggests that direct application of the classification proposed in this study to a range of care coordination models, particularly in PHC, may not be suitable.…”

“…There is no one accepted definition of care coordination [2]; its implementation follows diverse rules, regulations, guidelines, and service models [3, 4]. Despite it being a concept that requires clarification [5–7], health care organisations have increased investment in care coordination service models to improve health outcomes for patients with complex chronic care and social support needs and to reduce the burden and complications of hospital re-admissions. To meet the needs of this growing patient group, new care coordination roles that traverse generalist and specialist clinical roles have burgeoned.…”

Policy agenda for nurse-led care coordination

“…The imperative for patient-, family-and populationcentered interprofessional approaches to care coordination and transitional care: A policy brief by the American Academy of Nursing's CCTF, Nursing Outlook 60 (2012), 330-333. (Cipriano, 2012). The importance of health information technology in care coordination and transition care, Nursing Outlook 61 (2013), 475-479.…”

“…The importance of robust measures of care coordination practice was highlighted in each of the foundational papers reviewed by members of the CCTF. AAN's policy briefs on patient-, family-and populationcentered interprofessional approaches to care coordination and transitional care and health information technology recommended immediate policy action to "expedite funding to develop, implement and evaluate performance measures that address gaps in effective and efficient care coordination" (Cipriano, 2012) and harmonize data elements and standards requirements for a single patient-centered, consensus-based, longitudinal plan of care that is interoperable and accessible to patients, families, and all providers across all settings (Cipriano et al, 2013). ANA's white paper on the value of nurse care coordination and its framework for measuring nurses' contributions to care coordination specified principles to guide measurement development, including transparency, parsimony, evidencebased, comprehensiveness, and interprofessional teamwork, as well as measurement domains associated with effective nurse care coordination practice.…”