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Care coordinators go by many names and wear many hats

EDITOR'S NOTE: Carole Jakucs, MSN, RN, PHN, is a freelance writer.
Healthcare has seen many changes over the last few years, among them the move to improve care coordination and help patients transition successfully out of the hospital and back to their homes or onto their next level of care post-discharge.
“Effective care coordination helps to advance the care plan during the inpatient stay, then helps to transition patients to the most appropriate post-acute setting, said Mary Noli Pilkington, BSN, RN, CCM, interim director, care coordination and clinical social work at the University of California at Los Angeles Medical Center, for both the Westwood and Santa Monica campuses.
Nurses working in the care coordination and transition management role also are patient advocates, said Cathryn Kelly, MSN, RN, LDN, CCCTM, a manager with Populytics, a population health management and analytics company and wholly owned subsidiary of Lehigh Valley Health Network, based out of Allentown, Pa., and director with the Medical-Surgical Nursing Certification Board board of directors.
“Assessing patient goals, helping patients reach an optimum level of functioning and wellness, supporting chronic disease management, involving the patient and family in the plan of care, and functioning as part of an interdisciplinary team, are all part of the work of a care coordinator/transition manager,” said Kelly.
Managing expectations of the patient and family while walking them through challenges and a difficult time in their life, are also part of the job said Kelly. “We help patients and their families understand the trajectory of their illness to understand their prognosis and formulate plans to offer and provide external support when needed,” she said.
If the patient will be discharged home with a feeding tube for example, care coordinators and transition managers work to anticipate and plan for all the steps required to make this happen Luther said.
“This includes making sure they have the support of a family member at home to assist them, but also that they have the supplies they need — this in addition to providing the teaching and training necessary for the patient and family members participating in their care, so they can function once they’re home,” she said.
Assess, reassess, repeat
The terms care coordinator, transition manager, case manager, patient navigator and patient care facilitator are titles that are sometimes used interchangeably, said Ann Luther, MSN, RN, ACNS-BC, CORLN, a case manager with the Transition Management Office at Vanderbilt University Medical Center in Nashville, Tenn., but the goal is the same — “to ensure a safe, appropriate transition to the next place after discharge,” she said.
“There are several components addressed to make this happen,” Luther continued. “First you have to anticipate the various medical needs of the patient. You also have to assess their financial resources, look at their family situation and get their family on board and in agreement with the plan of care, and utilize the multidisciplinary team to address all the patients’ needs.”
This level of coordination is integral to patient care and assisting patients and clients across the care continuum, said Noli Pilkington.
“In the inpatient setting, care coordination utilizes the nursing process to assess, implement, reassess and risk stratify for patients — in collaboration with the multidisciplinary team,” she said. “You can truly impact patient outcomes and the trajectory of their condition and help them get back to a state of well-being and homeostasis, to the extent possible for their situation.”
The advocate hat
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Do you have the skills?
For nurses interested in moving into the care coordination/transition management role, the essential skills necessary for this work are problem solving, critical thinking, strong communication and collaboration skills and having the ability to engage in patient advocacy, said Luther. “If a nurse is considering this role, having a strong clinical background at the bedside in med-surg, ambulatory care as a clinic triage nurse, and working as a home health nurse is helpful, along with building knowledge and skills in your specialty area,” she said. “I also recommend following a [care coordinators/transition managers] if possible, to observe their practice and see what the work entails.” Noli Pilkington also recommends shadowing a care coordinator if you’re considering this job and advises to consider choosing continuing education untis on care coordination and transition management topics to learn more about the work. “Having experience in direct patient care in an inpatient setting in med-surg, the ED or ICU is invaluable,” she said. “Having a background in ambulatory care, home health or a skilled nursing facility is also helpful. Obtaining a bachelor’s or master’s degree is additional preparation that’s recommended. Once in the role of a care coordinator and transition manager for the required amount of time, board certification is an option to consider to continue professional development.” To learn more about care coordination, transition management and certification in this specialty, view the Care Transition Hand-Off Toolkit from the Academy of Medical Surgical Nurses.
Cathryn Kelly, RN
You can truly impact patient outcomes and the trajectory of their condition and help them get back to a state of well-being and homeostasis, to the extent possible for their situation.”
— Mary Noli Pilkington, RN

The role calls for attention to detail and a strong sense of collaboration

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By Carole Jakucs, MSN, RN, PHN
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