CHAPTER 4

ESSENTIALS OF CARE COORDINATION CLINICAL REASONING

In the current health care arena, nursing practice requires critical, creative, systems, and complexity thinking. Articulating and managing competing values are also a necessary component of care coordination. In many health care settings, nursing care plans have been replaced by interprofessional checklists, care maps, and critical pathways. These critical paths are road maps that help determine the progress that a patient is or is not making along a predetermined treatment plan. Maps and pathways do not absolve nurses from clinical reasoning responsibilities or making clinical judgments about care patients receive. What happens, for instance, if a patient deviates from the path? How does one reason about deviations from the norm? Clinical reasoning is essential when there is no standard plan or when patients deviate from the expected trajectory. Under these circumstances, professional nurses draw on past experiences, use accumulated knowledge, analyze existing data, consult with colleagues across health care contexts, and jointly formulate a plan of care to remedy patient issues.

The major focus of current health care practice is achieving positive patient health outcomes. To function effectively in this arena, nurses need outcome-specification skills. Previous nursing process models and many nursing diagnoses were organized around problem lists. Clinical reasoning that focuses on outcomes is more valuable and cost-effective than clinical reasoning that focuses on problems. In fact, a well-formed outcome is the opposite of a defined problem. However, identification of outcomes is insufficient without attention to intervention and activities that support how outcomes will be achieved. So, in many instances, nurses and other health care providers must manage and negotiate competing values. Patients benefit from care coordination and case management (American Nurses Association [ANA], 2015) through management of competing values and making explicit the intangible value exchanges between and among providers on the team. The role of a case manager and a care coordinator is becoming essential for meeting patient health care outcomes. Advanced practice nurses, nurse practitioners, clinical nurse specialists, clinical nurse leaders, and other health care providers benefit from enhanced ways of thinking and reasoning that support successful care coordination on a day-to-day basis. Such care coordination is enhanced if advanced practice nurses are able to practice to the full extent of their education and license (Greiner & Kneber, 2003). Clinical reasoning for care coordination addresses the essentials of patient and family needs in dealing with health care problems and prioritizing activities.

LEARNING OUTCOMES

After completing this chapter, the reader should be able to:

CARE COORDINATION AND COMPETING VALUES

The Competing Values Framework (CVF), developed by Quinn and Rohrbough (1983), provides guidance and insights into some of the essential areas of organizational life and care coordination, for example, collaborating, creating, competing, and controlling. The model suggests that all organizations and groups must manage tensions between external and internal demands or forces as well as the dynamics of flexibility versus control. The juxtaposition of these elements creates four different domains, as well as tensions and polarities to manage among the values of collaborating and competing, and creating and controlling (Quinn, Bright, Faerman, Thompson, & McGrath, 2014).

Each of the four quadrants in the CVF is necessary for an organization or activity to realize efficiency, effectiveness, and success (Figure 4.1). For example, in terms of collaboration, people must understand themselves and communicate honestly and effectively. Collaboratively, individuals mentor and develop others and know how to participate and lead teams. Often this knowledge requires encouraging and managing constructive conflict. Competition enhances productivity and profitability. In this domain, vision and goal setting are a path to motivating oneself and others so that the systems can be developed and organized to get results. Creating and promoting the adoption of new ideas or clinical innovations require attention to judicious use of power and ethics as well as championing new ideas and innovations through negotiating commitments and agreements for implementing and sustaining change. Control contributes to the development of stability and continuity as people work and manage across functions, organize information exchange, measure and monitor performance and quality, and enable compliance.

FIGURE 4.1 Competing Values Framework for care coordination clinical reasoning.

To what degree do health care providers explicitly consider the values exchanged in the context of a care coordination scenario? Making value exchanges explicit in the care coordination process is likely to result in new insights, knowledge, learning, performance, and expectations in future health care systems (Allee, 1997). Discussions about value exchanges between and among patients and caregivers and providers are likely to result in role clarity and contributions that support more high-quality performance (Allee, 2003). Value network analysis is a method that comes from the business world to help explain the value-added aspects of individual, group, and team contributions to a business transaction or enterprise. Inviting discussions about intangible value exchanges highlights and underscores important contributions and relational dynamics among health care providers in the context of care coordination (Allee, 2008).

When a group of people get together to make something happen, it does not evolve in a linear and/or hierarchical way. Value networks help make explicit the collaboration and values exchanged in human-to-human network interactions (Allee & Schwabe, 2015). As the center of attention for health care needs moves from management hubs to diffuse and distributed webs of relationships between and among providers, each interaction supports a specific value exchange as participants partner for success (Allee, 2003). The dynamic relationships among individuals are collaborative, trusting, dynamic, and interdependent. In addition, they are embedded in the competing values of creating, competing with markets, controlling, and collaborating. Digital connectivity also impacts value networking through greater access to knowledge and information, enabling one to provide quick and effective work with complex activities that have multiple variables and frequent exceptions (Allee, 2003; Allee & Schwabe, 2015).

For example, review the types of values defined in Table 4.1. Consider the degree to which these value exchanges impact and contribute to care coordination. The definitions of the values, adapted from Allee and Schwabe (2015), are also framed as questions in Table 4.1 and can be used to make explicit the value-added elements of care coordination activities. Try to think about a situation or transaction in your own practice in which you provided or were the recipient of one or more of these intangible values.

The Care Coordination Clinical Reasoning (CCCR) model proposed in this book emphasizes the role of the advanced practice nurse as a care coordinator, enhances the nursing process, and takes into account activities intended to navigate competing values related to interprofessional practice. The CCCR framework highlights the complexity and systems interactions between and among the patient issues, the care needed, and the services provided. The CCCR systems model web discussed in this chapter enables one to visually represent the complexities and essential care coordination practice issues that support the organized thinking that focuses on the patients and/or family’s priority needs within the context of services provided within and between health care delivery systems. Taking the time to build the model and see connections between and among complementary and/or competing patient care needs and team values helps create desired outcomes and effective and efficient care coordination.

CLINICAL REASONING AND CARE COORDINATION: LEVELS AND PERSPECTIVES

The CCCR systems model provides a blueprint for consideration of the care coordination practice issues. The reality is that clinicians must think using multiple levels of perspective and transcend and transverse these different levels. Every patient has a story that is analyzed and evaluated by the disciplinary perspective and knowledge classification representations and systems unique to the discipline. As clinicians interpret and evaluate the patient’s story they filter the story through their disciplinary knowledge base. Such filtering leads each clinician to frame the story and give meaning to the fact patterns associated with the patient’s story. A specific patient frame results from filtering a patient’s story through a disciplinary lens of nursing, medicine, culture, gender, race, family, and/or pharmacological perspectives. Disciplinary framing then leads to a focus for intervention and care planning. Sometimes filters and frames must be negotiated with competing values in mind.

For example, each discipline reasons with a patient-centered focus. One has to think about the patient’s needs, problems, and outcomes. Once disciplines process patient-centered thinking, they move to the next level of reasoning, which is team centered, as the advanced practice clinician has to take into consideration the team deliberations and dynamics related to the care coordination process—collaborating, creating, competing, and controlling. Finally, team members must consider the context and systems as well as organizational challenges that exist in supporting care coordination. All three of these levels must be taken into consideration to fully appreciate and efficiently manage the care coordination process. The following sections explain in detail the structure, the content, and the process of clinical reasoning at different levels of perspective that guide and support advanced practice nursing professionals (and other health care providers) in the development of a care coordination competency mind-set. The clinical reasoning framework proposed suggests structure that can be used as a scaffold to support clinical reasoning. Worksheets provide ways and means for people to create visual representations of issues and relationships between and among issues. The proposed model can be used to support teaching and learning and also to stimulate a pedagogical research agenda (Quinn, Heynoski, Thomas, & Spreitzer, 2014; Rahim & Goolamally, 2014).

TABLE 4.1 Value-Added Reflection Questions

Adapted from Allee, Schwabe, and Babb (2015).

The Outcome-Present State-Test (OPT) clinical reasoning model and the CCCR systems model provide the structure to organize the systems and complexity of reflective thinking needed to pinpoint the juxtaposition of present states with desired health outcome states. It is essential that disciplines and individual providers of care be alert and attentive to the philosophy, beliefs, and values, as well as the standardized health care language used to document problems, interventions, and outcomes for each of the health care disciplines involved in the care coordination process. The clinical vocabulary or knowledge content for clinical reasoning consists of the standardized languages or knowledge representations that are used to communicate between and among interprofessional health care providers. Knowledge regarding how domains of practice are influenced by standardized language is useful for interprofessional communication. As individual providers reflect on care coordination contributions and competing values, it influences and affects team reflection and leads to yet another level of reflection in the contexts of organizations and systems in which care is provided. These multiple levels of perspective provide insights and guidance related to the evaluation and effectiveness of care coordination efforts.

CLINICAL REASONING CARE COORDINATION ESSENTIALS

To reiterate from Chapter 1, the core competencies suggested by the Institute of Medicine (IOM) include providing patient-centered care, working in interprofessional teams, employing evidence-based practice, applying quality improvement, and using informatics (Greiner & Knebel, 2003). These competencies are embedded in a number of essential documents (American Association of Colleges of Nursing [AACN], 2011). The CVF described earlier in this chapter also is a useful lens through which to consider how teams best navigate issues of collaboration, creating, competing, and controlling in service of making intangible value exchanges explicit in the care coordination process.

When the advanced practice clinician surveys the various care coordination models and programs, there are care coordination essential needs included in each case management situation to help guide the plan of care toward successful outcomes. These responsibilities and foci are necessary for the individual care provider as well as the team who is responsible for patient-centered care coordination. In addition, Haas, Swan, and Haynes (2014) have identified the essential competencies and essentials of care coordination in a curriculum for ambulatory care nurses. Some of the essentials that all these models share are:

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