The hospital industry only recently acknowledged that coordination of care is essential to avoiding patient complications and reducing readmissions. Yet nurses have been addressing the issue for years. Now that finances are at stake, the traditional “captain of the ship” wants to seize ownership for coordinating care—but turns to the first mate RN and asks, “What should we do?”

Care coordination is a key strategy for addressing the Centers for Medicare and Medicaid (CMS) penalties taking effect this month for certain unnecessary readmissions 30 days postdischarge. Although the penalties have been criticized for lack of evidence-based methodology and unfairness, it’s hard to argue with the need to avoid unnecessary hospitalizations. Recognizing the tremendous challenges to reducing readmissions, CMS offers the “Community-Based Care Transitions Program,” which aims to improve the transition of high-risk patients from inpatient hospital care to other care settings, thereby reducing hospital readmissions. The program helps hospitals with above-average readmission rates partner with community-based organizations to improve the care transition experience.

Care coordination is one of the eight key principles of the National Priorities Partnership shepherded by the National Quality Forum (NQF), which aim to achieve better and more affordable care and to promote healthy people and communities. In 2006, the NQF Care Coordination Steering Committee defined care coordination as “a function that helps ensure the patient’s needs and preferences for health services and information sharing across people, functions, and sites over time. Coordination maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and high-quality patient experiences and improved healthcare outcomes.” Nurses have been providing these services for as long as we can remember in both general and specific roles and across all settings.

One high-profile proposed federal program spotlighting care coordination is the Medicare Shared Savings Program, which creates Accountable Care Organizations (ACOs). ANA has commented on the proposed rule for ACOs, calling out lack of recognition of RNs’ important work and setting the record straight about nurses’ longstanding role in care coordination: “ANA believes that CMS has largely neglected to include the contributions of nursing in its provisions and parameters describing integrated practice in general, and the ACO in particular. Care coordination is a building block on which much of the ACO quality improvement and cost control provisions are built. And care coordination is a core competency for the nursing profession; it is what nurses do. Yet the proposed rule largely disregards the contributions of professional nursing in both clinical services and patient management, and as a result, loses the opportunity for real cost savings.” (See http://www.nursingworld.org/AccountableCareOrganizations for the full document.)

Plans of care are integral to care coordination. Some people suggest a plan of care is a set of orders that spells out a patient’s disposition from one setting and one provider to another—medications, follow-up tests, and return visits. But such a plan isn’t patient-centered and neglects vital areas, such as functional challenges, side effects, and changes affecting the family unit. Nurses have a long history with plans of care that have transitioned from ritualized documents to tools outlining evidence-based practice interventions. Equally important, they include actions to address individual human responses to illness.

Nurses must lay claim to and receive recognition for leading care coordination. Insurance companies have figured it out and now brag about having nurses who help patients manage their care and well-being. Nurses also provide chronic disease management and interventions that minimize emergency department visits and prevent unnecessary hospitalizations. Home health nurses initiate personalized plans of care to enhance safety, recovery, and independence. Nurse leaders have gained national recognition for their work to improve transitions in care. For example, Geri Lamb, cochair of the NQF Care Coordination Steering Committee and associate professor at Arizona State University College of Nursing and Health Innovation, has researched how nurses coordinate care to determine best practices. Mary Naylor, professor of gerontology and director of the New Courtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, developed, tested, and refined the transitional care model—an evidence-based approach for coordinating the successful transition of chronically ill, high-risk older adults from hospital to home with a transitional care nurse to streamline and manage care, helping to avoid emergency visits and rehospitalization.

It’s time for us to leverage our experience and knowledge to take command of the care planning and care coordination processes. Perhaps some colleagues are merely ignorant of nurses’ expertise in these areas—or perhaps they doubt nurses can and should lead these initiatives. President Truman said, “It is amazing what you can accomplish if you do not care who gets the credit.” But this isn’t the time for us to be demure. We can be good team players while claiming these actions as ours and gaining appropriate recognition. It’s central to our care. We can “captain” this work.

Pamela F. Cipriano, PhD, RN, FAAN, NEA-BC
Editor-in-chief
American Nurse Today