CHAPTER 5

THINKING SKILLS THAT SUPPORT CARE COORDINATION CLINICAL REASONING

This chapter offers an introduction and overview of the thinking skills that support care coordination clinical reasoning (CCCR). Although not a new concept, care coordination is an evolving model of care that supports the desired achievement of triple aim, with goals for improved patient experiences of high-quality care, reduced costs, improving the health of populations. The information presented explores differences between case management and care coordination, and develops the argument that nurses, especially advanced practice nurses, by virtue of their knowledge, skills, and experiences, are in the best position to coordinate care. The discussion highlights the importance and value of advanced practice preparation and development of a CCCR skill set as the means to influence and lead care coordination at the provider, interprofessional team, and organizational levels.

Advanced practice registered nurses (APRNs) add value to care coordination because the education and training they receive promote the development of clinical reasoning skills that are necessary to manage all facets of the health care landscape and because they value and include the patient as a key member of the health care team (Yang & Meiners, 2014). Care coordination combines evidence-based practice with patient preferences (Goeree & Levin, 2006; Haas, Swan, & Haynes, 2014). CCCR skills can be enhanced with didactic and clinical learning experiences that employ different types of thinking skills.

The complexity of CCCR involves several types of thinking providers use to reason about individual patient problems while concurrently considering the care coordination issues of working with a multiprofessional team within organizational and system contexts. The quality of care provided through these synchronized efforts can be evaluated by looking at value exchange and the impact of structure (facilities and organizational health care systems that manage care), processes (behavior of the provider when diagnosing and treating), and outcomes (resulting change in health status and satisfaction of the patient; Mullnix & Bucholtz, 2009).

LEARNING OUTCOMES

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

THE NEED FOR CARE COORDINATION

Given health care complexity, reforms are being put in place to include the proper use of resources and best practices that involve models and interventions that improve the quality of patient care. The misalignment of resources and incentives prevents effective allocation and coordination of care that supports good patient outcomes. The Institute of Medicine reported an analysis of a large group of Medicaid and Medicare/Medicaid patient claims for five large states to determine the cost of uncoordinated care (Owens, 2010). The uncoordinated care analysis in this report revealed costs that were 75% higher than matched patients whose care was coordinated.

The health professional who historically has coordinated patient and family care has been the nurse. In fact, advanced practice nurses are highly qualified health care practitioners who provide cost-effective, accessible, patient-centered care and have the education to provide care coordination and case management services sought in the context of health care reform (Stanley, Werner, & Apple, 2009). Thus, care coordination is evolving as a key focus for accountable care organizations (ACOs) because of the emphasis and need to promote shared plans of care and improve costs across health care services and settings (Patient Protection and Affordable Care Act, 2010). Care coordination is an essential skill that is familiar to nurses at all levels. Care coordination is an expected standard and core competency of professional nursing practice (American Nurses Association [ANA], 2015). The current attention to interprofessional education and practice is giving rise to new opportunities for nurses to educate colleagues about the care coordination they have been providing to patients and families for many years.

The difference in scope of practice between RNs and advanced practice nurses is significant for future care coordination models because advanced practice nurses can directly, autonomously, and, with great flexibility, manage care activities and be compensated for their coordination activities (Laughlin & Beisel, 2010; Naylor et al., 2004). When RNs are to be used for care coordination efforts, educational strategies to prepare them and additional costs in practice overhead are incurred in order for their work to be sustained (Moore & Coddington, 2011).

Persons aged 85 years and older are growing at four times the rate of the U.S. population and, by 2030, one in every five people will be 65 years and older (Tabloski, 2014). American’s average life expectancy has increased; at the same time, death rates for the 65- to 84-year-old age group have decreased (Touhy & Jett, 2012). The growth in this population is only one reason our nation is already experiencing a shortage of primary care physicians; this shortage is expected to increase dramatically at the same time nurse practitioner (NP) programs are “educating three primary care NPs to every one primary care physician” (Sustaita, Zeigler, & Brogan, 2013, p. 42). It has been projected that NPs and physician assistants will fill this gap and be able to competently provide primary care medical homes. The American Association of Nurse Practitioners (AANP, 2013) recognizes that 90% of credentialed NPs are actively practicing, with enrollment and graduation rates of NP programs steadily increasing. With decreasing reimbursement rates from the Centers for Medicare & Medicaid Services (CMS), the vast majority of NPs continue to see Medicare and Medicaid recipients. Primary care providers often need to coordinate care and perform the role of a care coordinator because they are the central point of care for the patient. Not only are NPs educated and fully competent to provide primary care medical homes, their efforts are also cost-effective.

APRNs, specifically NPs, are being touted as the future of primary care by the following organizations: American Academy of Nurse Practitioners, American Association of Nurse Practitioners, Gerontological Advanced Practice Nurse Association, National Association of Pediatric Nurse Practitioners, National Association of Nurse Practitioners in Women’s Health, and National Organization of Nurse Practitioner Faculties. To date, many of the advanced practice nurse–led models of care have demonstrated better coordinated care at lower costs for patients with multiple social and health care needs (Craig, Eby, & Whittington, 2011). Advanced practice nurses have the knowledge, skills, and abilities to be the key care coordinating agents in a system. The care coordination of the future is likely to be different from the case management of the past.

CONTRASTING CASE MANAGEMENT WITH EVOLVING DEFINITIONS OF CARE COORDINATION

Past notions of case management often referred to intense and extensive care coordination of individuals with complex physical, emotional, and social health care needs who are at risk of complications from comorbidities and high costs (Schraeder & Shelton, 2013). In these case management instances, individuals, with all of their complexities, were managed with cost-effectiveness in mind. APRNs in the role of clinical nurse specialists (CNSs) have had a positive impact on care organization through case management (Foss & Koerner, 1997). However, the emergence of new technologies and standardized documentation have impacted the nursing care coordination practice to include more intense management for at-risk and vulnerable populations across all settings. A holistic approach to care coordination provided by nurses includes physical health and social, mental, and spiritual needs. Nurses bring a unique perspective to care coordination through their roles and scope of practice (Institute of Medicine [IOM], 2001).

The relationship of case management and care coordination for APRNs is determined by their scope of practice. Scope of practice is defined as the activities an individual health care practitioner is allowed to perform within a profession as determined by the law and standards of care (Safriet, 2002). Other boundaries of the scope of practice include clinical competence, skill, knowledge, and training that evolves over time as needs and operations (technology) of the health care milieu are redesigned (Milstead, 2008). Although the debate between scope-of-practice laws and reimbursement for NP services continues across the country, it has been noticed that nurses are the health care providers who take initiative in patient care and are key facilitators for communication between patients and all providers (Yang & Meiners, 2014).

Nurses have historically worked collaboratively with other health care providers for many years to provide care management. And when they are in positions of managing models of interprofessional teams, results show the best clinical outcomes and reduced costs (Schraeder & Shelton, 2013). In the advanced practice role, the APRN is in a key position to provide horizontal or lateral leadership to manage and coordinate care to improve primary care availability, provide care of the underserved, redesign the role of public health, and restructure hospitals (Aiken & Salmon, 1994; American Association of Colleges of Nursing [AACN], 2004; Lancaster, Lancaster, & Onega, 2000; Radzyminski, 2005). As evidence-based practice is used by advanced practice nurses to inform clinical decisions, theory and values inform case management and the coordination of team efforts to provide quality care (IOM, 2001). New definitions are evolving regarding the elements, dimensions, and values of care coordination across health care contexts.

The National Quality Forum (NQF) defines care coordination as a “function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites that are met over time” (NQF, 2014, p. 5). The framework for examining and understanding care coordination identified five key domains: health care “home,” proactive plan of care and follow-up, communication, information systems, and transitions or handoffs (NQF, 2014). When care coordination is successful, it is associated with higher quality, improved efficiency, better patient experiences, and reduced costs. When it is not successful, inaccurate transmission of information, inadequate communication, inappropriate follow-up care, medical error, and overall lower quality outcomes are obvious. The care coordination focus for nursing is helping the patient/family navigate health care systems and transitions between and among providers and services. Therefore, a definition of care coordination seen from a nursing perspective provides a foundation on which educational methods and strategies support the development of clinical reasoning skills that provide the foundation for care coordination.

The Agency for Healthcare Research and Quality (AHRQ) considered several definitions of care coordination when developing the following:

The ANA (2015) supports and advances the core elements of care coordination (AHRQ, 2015; NQF, 2010) and espouses the following. Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. RNs have demonstrated leadership and innovation in the design, implementation, and evaluation of successful care coordination processes and models using a team approach. These methods help ensure that the patient’s needs and preferences are met over time with respect to health services and information sharing across people, functions, and sites. As a core professional standard and competency for all registered nursing practice, partnerships guided by the health care consumer’s and family’s needs and preferences are essential to the outcomes of quality care, satisfaction, and the effective and efficient use of health care resources. Qualified and educated RNs are positioned to provide care coordination services, particularly with high-risk and vulnerable populations.

What is common across all definitions of care coordination is the emphasis on attending to the needs and preferences of patients and families through the integrative activities of communication and mobilization of resources (Lamb, 2013). The advanced practice nurse is poised to facilitate the relay of information between providers and across settings for effective implementation of services. The model that the ANA proposes is evident in primary care, where the patient receives care from an integrated, multidisciplinary team with a staff care coordinator (ANA, 2012). The models vary however, in which case managers, care transition programs, disease management, and health information technologies are used to manage services. Although not all care coordination activities show benefit (Ayanian, 2009; Peikes et al., 2009), many of the models show that the nurse is the most appropriate care coordinator.

EXAMPLES OF CARE COORDINATION MODELS

The American Academy of Nursing (AAN) has highlighted more than 50 nursedriven programs in various settings with a variety of populations to reflect new thinking for the current reforms in health care systems (AAN, 2012). For example, models for acute care coordination use advanced practice nurses, patient navigators, and social workers. Results in one study showed greater telephone contact, increased use of home health RNs, rehabilitation services, and reduced emergency department visits that resulted in readmission after the placement of a care coordination program for care coordination (Robles et al., 2011). Care coordination with complementary therapies in a program managed by specially educated nurses and patient navigators showed a decrease in medical costs and an increase in hospital savings (Kligler et al., 2011). RNs and social workers were shown to impact inpatient health care costs by assessing and managing financial, social, and emotional needs of patients to obtain resources to manage care at home. The results are reduced inpatient-related costs as a result of decreased numbers of visits and the visits were less critical and shorter (Gundersen Lutheran Health System, 2013).

Care coordination involving transitions into the home was addressed by a study with NPs who specifically targeted frail elderly patients with multiple comorbidities (Naylor et al., 2004). Interventions included home visits for 3 months postdischarge and resulted in cost savings, increased survival time, and fewer readmissions. The significant impact of this model was shown by the NP flexibility to individualize the evidence-based plan of care with interventions appropriate to on-site and real-time patient needs.

Community-based care coordination has shown cost reductions while ensuring safety with chronically ill elderly patients by using interprofessional teams that include RNs, NPs, and recommended social worker interventions to educate and empower patients to manage their own home care (Atherly & Thorpe, 2011; Coleman, Parry, Chalmers, & Min, 2006; Laughlin & Biesel, 2010). Patients are in need of medication knowledge, financial access to medications, caregiver support, and other services for chronic illness and cognitive decline that could promote aging in place.

Another population in need of care coordination is children with special health care needs. Models that use interprofessional teams with RNs and NPs as care coordinators have shown to decrease unnecessary resource use, decreased emergency department visits, decreased hospital admissions, decreased medical office visits, and improved functional status of the children (Antonelli, Stille, & Antonelli, 2008; Farmer, Clark, Drewel, Swenson, & Ge, 2011; Gordon et al., 2007). The value-model project used certified pediatric NPs as care coordinators, which resulted in improved patient satisfaction and reduced navigation of barriers to care resulting from the practitioner’s autonomy to manage all aspects of care (Looman et al., 2012). Care coordination models in mental health care have shown reduced barriers to management of mental health conditions (Oxman et al., 2002) and greater response to treatment as compared with usual care (Dietrich et al., 2004). Depression outcome measures were met in many instances in a review of 55 randomized controlled trials with case management and monitoring by RNs (Christensen et al., 2008).

The benefit of team-based care with specially educated nurses as care coordinators, interfacing with physicians, pharmacists, social workers, nutritionists, and rehabilitation services, promotes the health care model of the future. As part of ACOs, nurses function as team members working alongside other providers to coordinate care across settings, including transitions into the community (Nursing Alliance for Quality Care [NAQC], 2014). In a cross-case analysis of six NP-led clinics, Shiu, Lee, and Chau (2012) discovered that physicians identified advanced practice nurses as the providers who promoted the integrated teamwork spirit and fostered collaboration of the multidisciplinary team.

Education, practice, and research initiatives are needed to promote and test the models and methods that achieve the best patient outcomes and most efficient use of resources. The core competencies that should be included in educational preparation to bridge the quality chasm in health care, as suggested by the Institute of Medicine, 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 the AACN (2011) essentials for advanced practice nurse education, so graduates are positioned for key roles to manage and coordinate care.

A review of the literature regarding disease-management program models across the globe reveals that successful programs have five characteristics in common: (a) larger programs yield better economic value, provide more reliable measurement results, allow ease for provider compliance, and use data to refine protocols and programs; (b) simplicity of care paths and single provider care coordination; (c) focus on patient needs and abilities for regular visits and preventative services; (d) information technology transparency to communicate goals, methods, outcomes, and data analysis; and (e) provide incentives for the patient and provider compliance (Brandt, Hartmann, & Hehner, 2010; Looman et al., 2012).

Synthesis of the literature in which reports and studies document nurse involvement in care coordination shows the following outcomes: (a) reductions in emergency department visits, (b) decreased medication costs, (c) reduced inpatient charges, (d) reduced overall charges for care, (e) average savings per patient, (f) increases in survival with fewer readmissions, (g) lower total annual Medicare costs for beneficiaries in pilot projects compared with control groups, (h) increased patient self-confidence in managing their own care, (i) improved quality of care, (j) increased safety of older adults during transition from acute care settings to home, (k) improved clinical outcomes and reduced costs, and (l) improved overall patient satisfaction (ANA, 2012). Nurses also play effective roles in relational coordination by developing relationships with patients and other types of care providers through the use of interpersonal communication skills (Yang & Meiners, 2014).

CCCR: LEVELS OF PERSPECTIVES AND TYPES OF THINKING

There is a complexity to CCCR, as nurses must reason about the individual client or patient while simultaneously considering the care coordination issues as they also grapple with the complexities of working in an interprofessional team that must struggle with organizational and/or system issues. So CCCR requires the concurrent consideration of several levels of perspective: patient-centered, team-centered, and system-centered reasoning.

If advanced practice nurses are to have a unique contribution to make for the future of care coordination models, it will require educational preparation and training to promote the clinical reasoning skills necessary to manage all the facets of the ever-changing health care landscape, and by including the patient as a key member of his or her own health team (Yang & Meiners, 2014).

Good practices in care coordination are clinical reasoning activities that examine the structure (facilities and management of the health care system), process (behavior of the provider when diagnosing and treating), and outcome (resulting change in health status and satisfaction of the patient) of clinical situations (Mullnix & Bucholtz, 2009).

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