Concept 50: Care Coordination

What is care coordination?

Care coordination is the deliberate organization of patient care activities and information among healthcare providers, patients, and families to achieve safer, more effective care.

What are the key goals of care coordination?

• Improve patient outcomes

• Reduce fragmentation

• Enhance efficiency

• Promote safe transitions between care settings

What roles do nurses play in care coordination?

• Advocate for patient needs

• Communicate with the healthcare team

• Manage transitions of care

• Provide patient education

• Monitor follow-up and outcomes

What are common care coordination models?

• Case management

• Transitional care

• Patient-centered medical home

• Chronic care model

A nurse is coordinating discharge for a patient with heart failure. Which actions reflect effective care coordination? (Select all that apply)
A. Scheduling follow-up appointments
B. Reviewing diet and medication teaching
C. Assuming the patient will arrange their own transportation
D. Communicating medication changes to the primary care provider
E. Ensuring the patient has home health referral if needed

A, B, D, E.

• Coordinating follow-up, education, communication, and referrals are all essential parts of care coordination. Assuming the patient will manage transportation without assessing needs is a barrier.