Thursday April 25th 2019

New topic focuses on trends, challenges in care coordination

The five new articles in the September OJIN: The Online Journal of Issues in Nursing topic, Care Coordination: Benefits of Interprofessional Collaboration discuss a variety of aspects related to a team approach for care transitions.

Older adults with multiple chronic conditions complicated by other risk factors, such as deficits in activities of daily living or social barriers, experience multiple challenges in managing their health care needs, especially during episodes of acute illness. Identifying effective strategies to improve care transitions and outcomes for this population is essential. In “Continuity of Care: The Transitional Care Model,” authors Karen B. Hirschman, PhD, MSW; Elizabeth Shaid, MSN, CRNP; Kathleen McCauley, PhD, RN, FAAN; Mark V. Pauly, PhD; and Mary D. Naylor, PhD, RN, FAAN, provide a detailed summary of the evidence base for the model and review its nine core components.

The 2013 addition of the Care Transition Measures to the Hospital Consumer Assessment of Healthcare Providers and Systems survey, enactment of the Patient Protection and Affordable Care Act, and a greater focus on population health have brought a heightened awareness of and need for action with patient transitions. An article by Suzanne DelBoccio, MS, RN, CENP, and colleagues, “Successes and Challenges in Patient Care Transition Programming: One Hospital’s Journey,” describes the process to overcome patient care transition obstacles, with ultimate achievement of designation as a top performer. Included is discussion about efforts to personalize patient outcomes and transition through activation, and to improve transitions for vulnerable populations.

A fundamental component of the medical home model is care coordination. Children with medical complexity often require care from multiple specialists and community resources. The article, “Pediatric Care Coordination: Lessons Learned and Future Priorities,” by Rhonda G. Cady, PhD, RN, and colleagues, describes the need for specialized models of care coordination for CMC and provides detailed information about two models of care coordination for CMC specifically developed to address this challenge.

In the article, “Registered Nurse Care Coordination: Creating a Preferred Future for Older Adults with Multimorbidity,” authors Jean Scholz, MS, RN, NEA-BC, and Judith Minaudo, MS, RN, define care coordination, briefly describe trends for older adults and care coordination, and explore roles for RNs. A brief exemplar provides an example of evidence-based care coordination services provided by a nursing and social work team, a model supported by recent literature.

A key component of transition is information exchange, especially in long term care. However, long term care is often behind other settings in adoption of health information technologies. In the article, “Care Transitions in Long Term Care and Acute Care: Health Information Exchange and Readmission Rates,” Brian Yeaman, MD; Kelly J. Ko, PhD; and Rodolfo Alvarez del Castillo, MD, describe a pilot project using health IT and secure messaging in long term care  to facilitate electronic information exchange during care transitions. The authors offer implications for practice and research for implementation of health IT and information exchange across care settings that may contribute to reduction in readmission rates in acute care and the ED.

Read these articles at www.nursingworld.org/OJIN.

— Jackie Owens is the editor of OJIN.

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