chapter 2provement, safety, and informatics. these competencies are now part of nursing education...

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Table of Contents

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A Message from AAACN President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Expert Panels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv

Chapter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Introduction

Chapter 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Advocacy

Chapter 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Education and Engagement of Patients and Families

Chapter 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Coaching and Counseling of Patients and Families

Chapter 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Patient-Centered Care Planning

Chapter 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Support for Self-Management

Chapter 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Nursing Process (Proxy for Monitoring and Evaluation)

Chapter 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Teamwork and Collaboration

Chapter 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101Cross-Setting Communications and Care Transitions

Chapter 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113Population Health Management

Chapter 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141Care Coordination and Transition Management (CCTM) Between Acute Care and Ambulatory Care

Chapter 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163Informatics Nursing Practice

Chapter 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175Telehealth Nursing Practice

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199

AAACN Fact Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

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A Message from AAACN President

Health care reform and the Patient Protection and Afford-able Care Act (2010) challenged the American health

care system to find ways to manage the complex healthneeds of the population by increasing access to care andmanaging costs while providing the highest quality of care.Interprofessional patient-centered care models like the Pa-tient-Centered Medical Home and Accountable Care Or-ganizations are designed to provide personalized caremanagement with “RNs ideally positioned to serve in thecare coordinator/transition manager role” (Haas, Swan, &Haynes, 2013, p. 45). Safe, efficient, and effective transitionsbetween providers, levels of care, and various care settingswill be key factors to the success of these models.

The vision for this much anticipated text grew out of theneed and desire for evidence-based registered nurse (RN)competencies to provide education for and demonstrate theeffectiveness of the role of the RN in care coordination andtransition management (CCTM). The American Academyof Ambulatory Care Nursing (AAACN) developed an actionplan in 2011 to initiate this endeavor. The project includedthree phases for the core curriculum development and afourth phase to include the development of an online edu-cation course (Haas et al., 2013).

Four separate interprofessional Expert Panels wereconvened. The first reviewed and analyzed the literature.The second defined the nine dimensions and the core com-petencies and associated activities related to RN care co-ordination and transition management. The third built uponthe work of the first two panels and created the table of ev-idence which includes the competencies and the knowl-edge, skills, and attitudes necessary to fulfill this importantrole. A fourth panel of nurse leaders and experts from am-bulatory and acute care was enlisted to develop and createthis Core Curriculum and the online course correspondingto the content of the text.

For our three editors – Sheila A. Haas, PhD, RN, FAAN;Beth Ann Swan, PhD, CRNP, FAAN; and Traci S. Haynes,MSN, RN, BA, CEN – this project has been a labor of love!They have worked tirelessly to facilitate the work of the Ex-pert Panels and to champion the publication of this cutting-edge text and educational course that will serve as a CCTMresource for all registered nurses. The AAACN Board of Di-rectors and I thank our editors, the nurses and other pro-fessional colleagues who served on the Expert Panels, andthe authors and reviewers who worked so diligently to bringthe vision of this Core Curriculum to reality. We also ac-knowledge the Academy of Medical-Surgical Nurses(AMSN) for their collaboration in serving on the Expert Pan-els; for their assistance in developing the chapter “Care Co-ordination and Transition Management Between Acute Careand Ambulatory Care;” and for their endorsement of theCore Curriculum.

I hope that you find this outstanding publication to be avaluable resource in your nursing practice wherever you co-ordinate care or manage patient transitions.

Susan M. Paschke, MSN, RN-BC, NEA-BCAAACN President, 2013-2014

References

Haas, S., Swan, B.A., & Haynes, T. (2013). Developing ambulatory careregistered nurse competencies for care coordination and transitionmanagement. Nursing Economic$, 31(1), 44-49, 43.

Patient Protection and Affordable Care Act. (2010). Public Law 111-148, § 2702, 124 Stat. 119, 318-319.

The wait is over! The Care Coordination and Transition Management

(CCTM) Core Curriculum Is Here

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Foreword

Health care has been in continual change over the pastfew decades, implementing multiple strategies to im-

prove outcomes. Nurses are increasingly positioned to helplead these changes through advancements in nursing ed-ucation and refocusing professional practice models. Com-petency models are one strategy for improving care bydescribing standardized care objectives that address theshortcomings identified in the Institute of Medicine reportTo Err is Human (IOM, 1999), and the quality goals de-scribed in the Crossing the Quality Chasm report (IOM,2001). These reports revealed startling gaps in health careand proposed a quality framework, STEEEP, to improvecare outcomes: all care should be Safe, Timely, Equitable,Efficient, Effective, and Patient-centered. These goals, inaddition to changes from the 2012 Affordable Care Act, arechanging health care access, delivery, and reimbursementdramatically. The 2010 IOM report Future of Nursing calledfor nurses to practice to their fullest preparation and alsoto seek advanced educational mobility to lead changes inimproving care. Thus, nurses are uniquely positioned toprovide key leadership in improving care managementacross the myriad care delivery settings, but need guide-lines for specific settings and populations that help meetnew regulations and reimbursement demands.

A Competency-Based ResourceThis Care Coordination and Transition Management

Core Curriculum is a just-in-time competency-based re-source to guide nurses in the new delivery systems andpayment directives. Increasing complexity of care, diversepractice settings, and payer requirements are key factorsthat position nurses to have a leading role in care manage-ment across providers and transitions in care. The CoreCurriculum addresses competencies for improving careoutcomes among the multiple dimensions of growing com-plexity of care in diverse settings, and, in particular, ambu-latory populations. Most guidelines and evidence-basedstandards have been developed based on acute care in-patient experiences without addressing care needs acrosstransitions in settings or multiple providers. The three edi-tors of this text have carefully researched the competenciesneeded for new care management roles, both inpatient andoutpatient, to coordinate and manage care effectively.

Edited by three experts in ambulatory care who haveeach served as president of the American Academy of Am-bulatory Care Nursing, the Core Curriculum provides a fu-turistic perspective that integrates the award-winning andwidely adopted Quality and Safety Education for Nurses(QSEN) competency model (American Association of Col-

A Competency Model to Improve Quality and Safety,Care Coordination, and Transitions

leges of Nursing, 2012; Cronenwett et al., 2007). The goalof QSEN (www.QSEN.org) is the integration of the six com-petencies into all of nursing so that quality and safety arepart of nurses’ daily work: patient-centered care, teamworkand collaboration, evidence-based practice, quality im-provement, safety, and informatics. These competenciesare now part of nursing education standards and other reg-ulatory and certification guidelines.

The Care Coordination and Transition ManagementCore Curriculum provides a critical step in improving qualityand safety of care and helps nurses understand better howto incorporate the QSEN competencies in practice. Patient-centered care is at the heart of safety; the Care Coordina-tion and Transition Management standards describespecific evidence-based principles for accurate and per-sonalized assessment as the basis for patient-centeredcare. Safety awareness is even more important in consid-ering the unique practice settings that include advancedpractice nurses who may be in independent or group prac-tice, nurses who must communicate and share care goalsamong interprofessional colleagues, and those who man-age small care teams or supervise unlicensed personnel.Recognizing breakdowns in processes is the first step todevelop quality improvement initiatives that can close gapsbetween ideal and actual performance measures. Compe-tency in informatics provides a key strategy for communi-cation, decision support, and documentation.

Making Care Standards AccessibleThe potential power of this Core Curriculum is in mak-

ing care standards readily accessible to nurses. Standard-ization in care is a major component of safe care.Evidence-based standards share best practices based onthe latest evidence gathered from the literature and docu-mented experiences. Nurses are the constant patient careproviders who spend the most time with patients, and assuch, have key information for making care decisions.Knowing when and how to speak up is critical for improvingcare outcomes. Many errors occur during transitions incare, whether between providers, between settings, or unit-to-unit transfers; standardized handoff processes and com-munication can assure care management withoutinterruption.

Competency objectives identifying the knowledge,skills, and attitudes for accomplishing work help to stan-dardize care by specifying competencies for providers in aparticular setting or population focus to successfully per-form functions or tasks. Competencies are defined by theknowledge needed for achievement, the skills that enable

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application, and the attitudes that shape caregiver re-sponses and influence decision making about care. Com-petency models can also provide measurement criteria forassessing competency achievement. Competency devel-opment includes developing clinical judgment, reflecting onimproving one’s work, and awareness of the context ofpractice (Tanner, 2006). Competency development is morethan achieving skills or completing tasks. A competency-based practice model guides organization of tasks within apatient-centered perspective to address needs in a partic-ular care delivery setting such as nursing in an ambulatorycare center or a specific patient population. Competencystatements identifying the knowledge, skills, and attitudescan be applied to developing educational curriculum orspecific training, identifying licensure and certification re-quirements, writing position descriptions, recruiting and hir-ing personnel, and/or evaluating employee performance.

Empowering Nurses and PatientsBuilding on the six QSEN competencies, the Care Co-

ordination and Transition Management Core Curriculumculminates in care guidelines across nine evidence-baseddimensions: self-management, patient and family educa-tion and engagement, communication and transition,coaching and counseling patients and families, nursingprocess, teamwork and collaboration, patient-centeredcare planning, decision support and information systems,and advocacy. The comprehensive nature of the compe-tencies can leverage improvements across all settings andproviders and be applied in multiple ways from orientationto evaluation. These competencies are about empoweringnurses and empowering patients applying the changemodel of Will, Ideas, and Execution. We know nurses havethe will to improve care when they have the ideas and havethe resources for execution. The Care Coordination andTransition Management Core Curriculum is a vital resourcefor all nurses that fits the current practice arena and hasthe capacity to improve care for all.

Gwen Sherwood, PhD, RN, FAANAssociate Dean for Academic Affairs and Professor

University of North Carolina at Chapel HillSchool of Nursing

Chapel Hill, NC

References

American Association of Colleges of Nursing (AACN). (2012). QSEN ed-ucation consortium: Graduate-level QSEN competencies, knowl-edge, skills and attitudes. Retrieved from http://www.aacn.nche.edu/faculty/qsen/competencies.pdf

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J.,Mitchell, P., Sullivan, D.T., & Warren, J. (2007). Quality and safety ed-ucation for nurses. Nursing Outlook, 55(3), 122-131.

Institute of Medicine (IOM). (1999). To err is human: Building a safer healthsystem. Washington, DC: National Academies Press.

Institute of Medicine (IOM). (2001). Crossing the quality chasm: A newhealth system for the 21st century. Washington, DC: National Acad-emies Press.

Institute of Medicine (IOM). (2010). The future of nursing: Leading change,advancing health. Washington, DC: The National Academies Press.

Tanner, C. (2006). Thinking like a nurse: A research based model of clinicaljudgment in nursing. Journal of Nursing Education, 45(6), 204-211.

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The passage of the Patient Protection and AffordableCare Act (ACA) in 2010 has provisions fosteringmovement from a focus on acute care to care across

the continuum with wellness, health promotion, and diseaseprevention. Settings for care, again fostered by the ACA, arethe Patient-Centered Medical Home (PCMH) and Account-able Care Organizations. ACA provisions offer many oppor-tunities for access to primary care for patients and forcontributions by ambulatory care nurses as well as for nursesworking in acute, subacute, and home care. The ACA alsohas provisions that mirror the Institute of Medicine’s (IOM,2001) Crossing the Quality Chasm report recommendationsfor health care reform, including the need for care to be safe,effective, patient centered, timely, efficient, and equitable.Other ACA provisions are focused on use of evidence-basedpractice to guide care provided by interprofessional teams.Again, in PCMHs and other ambulatory care settings, theseexpectations spelled out in health care reform legislation offeropportunities for ambulatory and acute care nurses to bemajor contributors. Finally, another IOM report, The Future ofNursing: Leading Change, Advancing Health (2010), in-cludes recommendations, two in particular, that speak directlyto opportunities for all nurses in this era of health care reform:(a) Nurses should practice to the full extent of their educationand training, and (b) Nurses should be full partners, withphysicians and other health care professionals, in redesigninghealth care in the United States (IOM, 2010).

The Care Coordination and Transition ManagementCore Curriculum for Ambulatory Care Nursing is a compre-hensive, evidence-based guide designed to support theAmerican Academy of Ambulatory Care Nursing’s (AAACN)mission: “To advance the art and science of ambulatory carenursing” and provide a valid and reliable care coordinationand transition management model and practice resource fornurses (AAACN, 2014). Recognizing that demand for pri-mary and specialty care would increase with enactment ofthe ACA and that the numbers of patients with complexchronic illnesses were increasing, the AAACN decided toinvest in a translational research project to define the dimen-sions of care coordination and transition management(CCTM). This foundation could provide for development ofCCTM competencies for nurses and evidence-based con-tent for professional education and continuing developmentof ambulatory and acute care nurses working in new modelsof care delivery in PCMHs and other care settings.

This Care Coordination and Transition ManagementCore Curriculum is one outcome of the CCTM project. ThisCore Curriculum text is designed for registered nurses cur-rently working in ambulatory care and acute care settings

who aspire to move into the RN in CCTM role as well as fornurses who are considering transitioning into ambulatory orother settings where they desire to develop CCTM knowl-edge, skills, and attitudes that are essential to the CCTMrole. The Core Curriculum is a rich, evidence-based re-source that can enhance nursing student experiences inambulatory, acute, subacute, and home care settings. ThisCore Curriculum uses the Quality and Safety in Nursing Ed-ucation (QSEN) Competency framework (Cronenwett et al.,2007) that specifies knowledge, skills, and attitudes (KSA)for each of the nine Registered Nurse Care Coordinationand Transition Management dimensions. The unique KSAtables included in each chapter provide a rich resource bysummarizing chapter content and enhancing understandingof the breadth and depth of each dimension. The tables cat-egorize requisite skills and attitudes that are needed in ad-dition to knowledge of content for each Care Coordinationand Transition Management dimension.

This undertaking could not have come to fruition withoutthe commitment and expertise of the volunteer AAACNmember expert contributors who participated in one or moreexpert panels and were authors of chapters in this CoreCurriculum. The AAACN Board of Directors and member-ship, as well as its association management firm, AnthonyJ. Jannetti, Inc., are to be commended for their vision, lead-ership, and support of this translational research project andthe publication of the Care Coordination and TransitionManagement Core Curriculum. We are proud to provide thistext to RNs who want to grow as care coordinators and tran-sition managers to better serve our most vulnerable patientpopulations.

Sheila A. Haas, PhD, RN, FAANLead Editor

Beth Ann Swan, PhD, CRNP, FAANCo-Editor

Traci S. Haynes, MSN, RN, CENCo-Editor and Project Manager

References

American Academy of Ambulatory Care Nursing (AAACN). (2014). Mem-bership. Retrieved from https://www.aaacn.org/membership

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mit-chell, P., … Warren, J. (2007). Quality and safety education for nurses.Nursing Outlook, 55(3), 122-131.

Institute of Medicine (IOM). (2001). Crossing the quality chasm. Washing-ton, DC: National Academies Press.

Institute of Medicine (IOM). (2010). The future of nursing: Leading change,advancing health (1st ed.). Washington, DC: National AcademiesPress.

Patient Protection and Affordable Care Act. (2010). Public Law 111-148, § 2702, 124 Stat. 119, 318-319.

Preface

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Learning Outcome Statement

The purpose of this chapter is to enable the reader todemonstrate the ability to develop, implement, and provideongoing management of a comprehensive plan of care –based upon the individual patient’s values, preferences, andneeds – in partnership with the primary care provider andlarger interdisciplinary care team.

Learning Objectives

After reading this chapter, the registered nurse (RN)working in the Care Coordination and Transition Manage-ment (CCTM) role will be able to:• Perform a comprehensive needs assessment on the

patient focusing on the overall needs so interventionscan be planned and implemented accurately.

• Identify gaps in care and individualize the plan focusthrough a pre-visit chart review and visit planning.

• Describe the process for identification of high-risk pop-ulations and determine appropriate risk.

• Utilize motivational interviewing as a communicationstyle to guide the patient and family planning to makepositive behavior changes to improve health.

• Develop a plan of care utilizing input from patient, family,and multidisciplinary team members.

• Design interventions founded in evidence-based clinicalguidelines.

• Demonstrate the knowledge, skills, and attitudes required for the patient-centered care planning dimen-sion (see Table 1).

Competency Definition

“Patient- and family-centered care is an approach tothe planning, delivery, and evaluation of health care thatis grounded in mutually beneficial partnerships amonghealth care providers, patients, and families” (Institute forPatient- and Family-Centered Care, 2014, para. 1).

CHAPTER 5

Patient-Centered Care PlanningJudith M. Toth-Lewis, PhD, MSN, RN

Kathleen T. Sheehan, MS, BSN, RN-BC, CH-GCNAnne Talbott Jessie, MSN, RN

In designing the plan of care, the registered nurse (RN)engaged in Care Coordination and Transition Manage-ment (CCTM) recognizes the integral role patients, fam-

ilies, and caregivers have in ensuring the health andwell-being of patients. Additionally, the RN in CCTM ac-knowledges that emotional, social, and developmental sup-port are critical components in the delivery of health care(The Institute for Patient- and Family-Centered Care, 2014).Engaging patients and their designees in care plan devel-opment supports improved patient outcomes, increases pa-tient and family satisfaction, restores dignity and control, andcontributes to financial stewardship in the allocation of re-sources. Core concepts for patient-centered care planninginclude (a) respect and dignity: honor perspectives, choices,values, beliefs, and cultural backgrounds; (b) informationsharing: timely, accurate, transparent, and complete com-munication; (c) participation: engagement and participationof patients and families in care and decision making; and(d) collaboration: inclusion of patients and families in pro-gram design, implementation, policy development, and pro - fessional education (The Institute for Patient- andFamily-Centered Care, 2014). The degree of inclusion is de-termined by the patient and does not preclude the patientmaking care decisions independently if he or she is com-petent to do so (The Institute for Patient- and Family-Cen-tered Care, 2014).

I. Comprehensive Needs Assessment

A. Psychosocial Assessment Tool: this is a Patient HealthQuestionnaire with 2 or 9 questions (PHQ-2 or 9) thatassesses patient for signs and symptoms ofdepression. According to Kroenke, Spitzer, andWilliams (2003), “the purpose of the PHQ-2 is not toestablish final diagnosis or to monitor depressionseverity, but rather to screen for depression in a firststep approach” (p. 1). A score of 3 or more requiresfurther inquiry using the PHQ-9 Questionnaire. Both

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questionnaires focus on the past 2 weeks. “The PHQ-9 is a multipurpose instrument for screening,diag nosing, monitoring and measuring the severity ofdepression” (Kroenke, Spitzer, & Williams, 2001, p. 1).1. PHQ-2 or 9 is handed to the patient to complete.2. It is scored by the primary care provider or another

member of the team.3. A positive screen PHQ-9 is further assessed for

presence and duration of suicide ideation.4. The questionnaire can be repeated at each visit to

reflect improvement or worsening of depressionand response to treatment.

5. Notify primary care provider for worsening signsand symptoms.

6. Emergent suicidal intervention for any planned in-terventions with adequate means to carry out in-tervention.

B. Functional assessment: the Katz Index of Indepen -dence in Activities of Daily Living (IADL) is the mostappropriate instrument to use in assessing functionalstatus when measuring a patient’s ability to performactivities of daily living independently (Katz, Down,Cash, & Grotz, 1970). “One of the best ways toevaluate the health status of older adults is throughfunctional assessment which provides objective datathat may further indicate decline or improvement inhealth status, allowing the nurse to plan and interveneappropriately” (Shelkey & Wallace, 2012, p. 1).1. Tool is used to detect problems in performing

ADLs.2. The index ranks adequacy of performing bathing,

dressing, toileting, transferring, continence, andfeeding.

3. RN in CCTM should plan for increased servicessuch as physical therapy, occupational therapy,and visiting nurse or aide services for patients whohave difficulties with ADLs.

C. Cage and Cage-AID: the CAGE-AID is a questionnairethat focuses on both drug and alcohol abuse. TheCAGE-AID is a conjoint questionnaire where the focusof each item of the CAGE questionnaire was expandedfrom alcohol alone to include other drugs (Brown &Rounds, 1995). Regard one or more yes responses toa positive screen. There are four questions to becompleted by the patient.1. Positive screen would follow-up with primary care

provider about drug and alcohol rehabilitation.2. Behavior medicine or behavioral health consult as

needed.3. Monitor at each visit to promote dialogue about the

problem.4. Recommend referral to Alcoholics Anonymous.5. Recommend referral to other drug or alcohol treat-

ment programs in the area.D. The Mini-Cog – Mental Status Assessment of Older

Adults: “Five and a third million Americans of all ageshave Alzheimer’s disease or other dementias. The

increased availability of successful treatments fordementia and dementia-related illnesses means thereis a substantial need for increased early identificationof cognitive impairment, particularly in the geriatricpopulation” (Doerflinger, 2013, p. 1).1. The Mini-Cog is a simple screening tool that takes

3 minutes to administer.2. Effective triage tool to identify patients in need of

further evaluation by a neurologist.3. Clock Drawing Test (CDT) is scored as normal or

abnormal.4. CDT is considered normal if all numbers are pres-

ent in correct sequence and position; hands arereadably displayed at the correct time. (Length ofhands is not a factor.)

5. Instruct patient to remember three words such astable, pencil, and apple.

6. Next, ask him or her to draw a clock showing thetime of 11:15.

7. Next, ask him of her to state the three recalledwords.

8. Award 1 point for each recalled word and 2 pointsfor correct CDT.

9. Score 0-2 is considered positive screen for de-mentia and requires prompt evaluation.

10. Early identification and intervention should lead tobetter outcomes.

E. Modified Caregiver Strain Index: “Caregivers may beprone to depression, grief, fatigue, financial hardship,and changes in social relationships. Screening toolsare useful to identify families who would benefit from amore comprehensive assessment of the care givingexperience” (Onega, 2013, p. 1).1. Thirteen question tool that measures strain related

to care provision.2. Covers five domains: financial, physical, psycho-

logical, social, and personal.3. Higher the score the higher the strain.4. Self-administered instrument by the client/care-

giver.5. Appropriate interventions are needed to help the

caregiver.6. Further assessment of the caregiver by his or her

primary care provider.7. Early intervention could prevent further deteriora-

tion in the patient and caregiver.F. Get Up and Go Test: “The timed Get Up and Go Test is

a measurement of mobility. It includes a number oftasks such as standing from a seating position,walking, turning, stopping, and sitting down which areall important tasks needed for a person to beindependently mobile” (Mathias, Nayak, & Issacs,1986, p. 387).1. Test is performed when patient is wearing regular

footwear, using usual walking aid, and sitting inchair with an armrest.

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Table 1.Patient-Centered Care Planning: Knowledge, Skills, and Attitudes for Competency

“Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinatedcare based on respect for patient’s preferences, values, and needs” (Cronenwett et al., 2007, p. 123).

Knowledge Skills Attitudes Sources

Integrate understanding ofmultiple dimensions of patient-centered care: • patient/family/community

preferences, values• coordination and integration

of care• information, communication,

and education• physical comfort and

emotional support• involvement of family and

friends• transition and continuity.

Describe how diverse cultural,ethnic and social backgroundsfunction as sources of patient,family, and community values.

Elicit patient values,preferences, andexpressed needs as partof clinical interview,implementation of careplan and evaluation ofcare.

Communicate patientvalues, preferences, andexpressed needs to othermembers of health careteam.

Provide patient-centeredcare with sensitivity andrespect for the diversity ofhuman experience.

Value seeing health care situations‘through patients’ eyes.’

Respect and encourage individualexpression of patient values, preferences,and expressed needs.

Value the patient’s expertise with ownhealth and symptoms.

Seek learning opportunities with patientswho represent all aspects of humandiversity.

Recognize personally held attitudes aboutworking with patients from different ethnic,cultural, and social backgrounds.

Willingly support patient-centered care forindividuals and groups whose values differfrom own.

Cronenwett et al., 2007

Demonstrate comprehensiveunderstanding of the conceptsof pain and suffering, includingphysiologic models of pain andcomfort.

Assess presence andextent of pain andsuffering.

Assess levels of physicaland emotional comfort.

Elicit expectations ofpatient and family forrelief of pain, discomfort,or suffering.

Initiate effectivetreatments to relieve painand suffering in light ofpatient values,preferences, andexpressed needs.

Recognize personally held values andbeliefs about the management of pain orsuffering.

Appreciate the role of the nurse in relief ofall types and sources of pain or suffering.

Recognize that patient expectationsinfluence outcomes in management ofpain or suffering.


Examine how the safety, quality,and cost effectiveness of healthcare can be improved throughthe active involvement ofpatients and families.

Examine common barriers toactive involvement of patients intheir own health careprocesses.

Describe strategies to empowerpatients or families in allaspects of the health careprocess.

Remove barriers topresence of families andother designatedsurrogates based onpatient preferences.

Assess level of patient’sdecisional conflict andprovide access toresources.

Engage patients ordesignated surrogates inactive partnerships thatpromote health, safetyand well-being, and self-care management.

Value active partnership with patients ordesignated surrogates in planning,implementation, and evaluation of care.

Respect patient preferences for degree ofactive engagement in care process.

Respect patient’s right to access topersonal health records.


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Source Note: Cronenwett et al. (2007) reprinted from Nursing Outlook, 55(3), 122-131, with permission from Elsevier.

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CHAPTER 5 – Patient-Centered Care Planning


Table 1. (continued)Patient-Centered Care Planning: Knowledge, Skills, and Attitudes for Competency


Explore ethical and legalimplications of patient-centeredcare.

Describe the limits andboundaries of therapeuticpatient-centered care.

Recognize theboundaries of therapeuticrelationships.

Facilitate informed patientconsent for care.

Acknowledge the tension that may existbetween patient rights and theorganizational responsibility forprofessional, ethical care.

Appreciate shared decision making withempowered patients and families, evenwhen conflicts occur.


Discuss principles of effectivecommunication.

Describe basic principles ofconsensus building and conflictresolution.

Examine nursing roles inassuring coordination,integration, and continuity ofcare.

Assess own level ofcommunication skill inencounters with patientsand families.

Participate in buildingconsensus or resolvingconflict in the context ofpatient care.

Communicate careprovided and needed ateach transition in care.

Value continuous improvement of owncommunication and conflict resolutionskills.


Describe strategies for learningabout the outcomes of care inthe setting in which one isengaged in clinical practice.

Seek information aboutoutcomes of care forpopulations served incare setting. Seekinformation about qualityimprovement projects inthe care setting.

Appreciate that continuous qualityimprovement is an essential part of thedaily work of all health professionals.


Recognize that nursing andother health professionsstudents are parts of systems of care and care processes thataffect outcomes for patients andfamilies. Give examples of the tension betweenprofessional autonomy andsystem functioning.

Use tools (such as flowcharts, cause-effectdiagrams) to makeprocesses of careexplicit. Participate in aroot cause analysis of asentinel event.

Value own and others’ contributions tooutcomes of care in local care settings.


Explain the importance ofvariation and measurement inassessing quality of care.

Use quality measures tounderstand performance.

Use tools (such ascontrol charts and runcharts) that are helpful forunderstanding variation.

Identify gaps betweenlocal and best practice.

Appreciate how unwanted variation affectscare. Value measurement and its role ingood patient care.


Describe approaches forchanging processes of care.

Design a small test ofchange in daily work.



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Learning Outcome Statement

The purpose of this chapter is to enable the reader tounderstand the outcomes a mutually developed, imple-mented, and continuously evaluated transition of care planhas on quality of care, patient satisfaction, and patient out-comes. In addition, recognizing the financial impact and un-derstanding the importance of integrating evidence-basedpractice guidelines into a transition of care plan are essentialcomponents of the role of the registered nurse (RN) in CareCoordination and Transition Management (CCTM).

Learning Objectives

After reading this chapter, the RN in the CCTM role willbe able to:• Identify opportunities for transition management within

the continuum of care.• Identify key elements of successful transition planning

including identification of vulnerable populations.• Review the most common factors influencing poor tran-

sition of care.• Describe components of an evidence-based transition

plan.• List examples of transition of care models.• Apply an evidence-based format to coordinate informa-

tion transfer between sites of care.• Demonstrate the knowledge, skills, and attitudes re-

quired for transitions in care (see Table 1).

Competency Definition

Transition of care is the movement of a patient fromone setting of care (hospital, ambulatory primary carepractice, ambulatory specialty care practice, long-termcare, home health, rehabilitation facility) to another (Cen-ters for Medicare & Medicaid Services [CMS], 2013a). “Itcomprises a range of time-limited services that comple-ment primary care and are designed to ensure healthcare continuity and avoid preventable poor outcomesamong at-risk populations as they move from one levelof care to another, among multiple providers and acrosssettings” (Naylor, Aiken, Kurtzman, Olds, & Hirschman,2011, p. 747). Transitional care is “a set of actions de-signed to ensure the coordination and continuity of healthcare as patients transfer between different locations ordifferent levels of care within the same location” (Coleman& Boult, 2003, p. 555).

CHAPTER 11

Care Coordination and Transition ManagementBetween Acute Care and Ambulatory Care

Janine Allbritton, MSN, RNMary Sue Dailey, APN-CNS

Until recently, much of the research conducted on tran-sition of care events emphasized hospitals and thedischarge planning process. It has become apparent

there are numerous instances along the continuum of careduring which the progress toward positive clinical outcomeshas the potential to derail. It is also becoming apparent thatresponsibility for a person’s care does not end when thatperson enters or exits another care setting. Through activeinvolvement of the patient and caregiver and participationof providers of care from environments outside the hospital,in concert with discharge planning occurring during hospi-talization, opportunities for preventing errors will be uncov-ered, preventable re-admissions will be decreased, andmore conscientious use of the shrinking health care dollarwill occur.

The coordination of patient care is an established stan-dard of nursing practice, regardless of the practice environ-ment. Engaging the patient and family to participate indetermining the needs and preferences surrounding theircare and providing education and securing essential equip-ment, supplies, and community resources to manage theircare has long been part of the scope of the practicing reg-istered nurse (RN). The American Nurses Association(ANA) released a position statement regarding the essentialrole of RNs in this endeavor. “Patient-centered care coordi-nation is a core professional standard and competency forall registered nursing practice. Based on a partnership

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guided by the healthcare consumer’s and family’s needsand preferences, the registered nurse is integral to patientcare quality, satisfaction, and the effective and efficient useof health care resources. Registered nurses are qualifiedand educated for the role of care coordination, especiallywith high risk and vulnerable populations” (ANA, 2012, para.2). In October 2012, Medicare began linking hospital reim-bursement to the quality of care. This increased focus onquality places more emphasis on better preparation of pa-tients for managing their illness at home. The goal is to pro-mote quality and cost savings through the reduction ofafter-hospital adverse events and prevent re-admissions. Inparticular, the ambulatory care RN plays a critical role incare coordination and transition management (CCTM) byfocusing on prevention of illness, management of specifichigh-risk conditions, reduction or elimination of preventablecomplications, as well as promotion of healthy lifestylechanges and careful use of valuable health care resources.Management of a care transition generally begins when apatient is identified as having a status change (deteriorationor improvement) that makes it appropriate to move to an-other setting or level of care (American Medical DirectorsAssociation [AMDA], 2010).

I. Transition of Care Opportunities

A. Acute to ambulatory care which includes transition ofcare from hospital to primary care physician.1. This is one of the most common transitions of care

to identify and one that has been researched themost.

2. Provides an opportunity to have a major impact onquality of care with effective hand-off communica-tion.

3. Is the transition of care most likely to positively im-pact health care cost savings through implemen-tation of strategies to reduce adverse events andhospital re-admission rates.

4. Contains communication gaps between providersin the acute care and post-hospital care agencieswhich results in providers having an incompletepicture of the scope of the patient’s needs.

5. Requires collaboration between inpatient or acutecare RN contact and the RN in CCTM in ambula-tory care, Patient-Centered Medical Homes(PCMH), and outpatient settings, both having ac-cess to multidisciplinary health care teams.

6. Provides opportunity for patients to further discussand solidify goals discussed but not finalized inacute care settings.

7. Home care agency must be made aware of perti-nent care information and patient needs to main-tain consistency in care and anticipate care needs.

B. Acute to sites within long-term care continuumrequires RN points of contact to facilitate com muni -cation between health care team at different levels ofcare.

1. Care transitions expose older adults to added riskfor medical complications, decreased quality of life,and overuse of acute health care services (NationalTransitions of Care Coalition [NTOCC], 2011).

2. Older adults now enter nursing homes with in-creasingly acute health conditions which meansthey are more vulnerable to poor health and qual-ity-of-life outcomes.

3. Nursing home residents are highly vulnerable toharm from poorly executed care transitions, includ-ing inadequate communication of critical informa-tion from the hospital, medication errors includingomissions, delays in follow-up diagnostic tests,treatments, and repeated hospitalizations.

4. The fundamental goal of those assisting olderadults during transitions of care is to promote safeand person-centered transitions that are mostlikely to achieve patient and caregiver goals with-out complications (AMDA, 2010).

C. Ambulatory care and extended care to acute care.1. Acute care RNs are generally responsible for col-

lecting data to establish a plan of care, but oftenhave incomplete information regarding patient’sprior health status, socioeconomic issues, supportsystems, and coping mechanisms. This is an op-portunity for the RN in CCTM to facilitate the ex-change of information.

2. In current practice, information previously devel-oped for a patient’s ambulatory or extended careplan of care is seldom shared with the acute caremedical team.

3. The RN in CCTM can assist in facilitating thetransfer of care to acute setting by ensuring and/orproviding the following elements:a. The patient should have an accountable

provider or a team of providers during all pointsof transition. This provider(s) should be clearlyidentified, will provide patient-centered care,and will serve as central coordinator acrossall settings and across other providers.

b. The patient should have an up-to-date, proac-tive care plan that includes clearly definedgoals, takes into consideration the patient’spreferences, and is culturally appropriate.

c. Whenever possible, the management and co-ordination of transitional care activities shouldbe facilitated through the use of integratedelectronic information systems that are inter-operable and available to patients andproviders.

d. Information must be communicated to theacute care setting on current prescription andover-the-counter medications (including vita-mins, herbs, laxatives, etc.) specifying name,dose, frequency, and duration.

e. Strategies for appropriate communication withpatients with limited English proficiency andhealth literacy must be defined.

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Table 1.CCTM Between Acute Care and Ambulatory Care: Knowledge, Skills, and Attitudes for Competency

Patient-Centered Care

Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care basedon respect for patient’s preferences, values, and needs (Cronenwett et al., 2007).


Analyze multiple dimensions ofpatient-centered care includingpatient/family/communitypreferences and values, as well as social, cultural,psychological, and spiritualcontexts.

Types of transitions:• Acute to home• Acute to subacute• Home to acute• Acute care to long-term

acute care

Identify patient andcaregiver main concernsregarding care afterdischarge, managementof symptoms, attainablegoals related to diseaseand prognosis.

Identify and create plansto address barriers incare settings that preventfully integrating patient-centered care.

Engage patients ordesignated surrogates inactive partnerships alongthe health-illnesscontinuum.

Commit to the patient as the source ofcontrol and full partner in his/her care.

Commit to patient-centered, collaborativecare planning.

Appreciate physical and other barriers topatient-centered care.

Value the involvement of patients andfamilies in care decisions.

Respect preferences of patients related totheir level of engagement in health caredecision making.


Analyze patient-centered carein the context of carecoordination, patient education,physical comfort, emotionalsupport, and care transitions.

Work to address ethicaland legal issues relatedto patients’ rights todetermine their care.

Work with patients tocreate plans of care thatare defined by thepatient.

Commit to respecting the rights of patientsin determining their plan of care.

Recognize the need to work with familymembers to accept the patient’s right forself-determination.

Value the decisions of patient and familyin choosing best next level of care basedon patient’s goals.

Physician Orders forLife-SustainingTreatment Paradigm(POLST), 2012

Analyze strategies whichempower patients and/orfamilies involved in the healthcare process.

Engage patients and/orcaregivers in developingactive partnerships at alllevels of care.

Eliminate barriers tofamily or other caregiver’spresence during carediscussions per patient’srequest.

Value the involvement of patients andfamilies in care decisions.

Respect patient preferences for degree ofactive engagement in care process.

Honor active partnership with patients ortheir designated participants in planning,implementing, and evaluating careprovided.



Source Note: Cronenwett et al. (2007) reprinted form Nursing Outlook, 55(3), 122-131, with permission from Elsevier.

chapter 2provement, safety, and informatics. these competencies are now part of nursing education...

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