Advanced Care Coordination Series: Populations and Settings
Topics in this Series are designed to inform RN Care Coordination practice specific to individual populations and practice settings.
Learning Option: Online
Online education is an effective course delivery strategy for learners who desire or need the convenience and flexibility to learn at their own pace and in their own environment. Online learning requires participants to be self-directed in completing program content. Comfort with technology and strong time management skills are a must. In this learning format, faculty utilize the Training Center’s eLearning platform to deliver lectures, course content, materials and practice resources and tools. Online Training is also available to organizations upon request.
How This Series Works
- Select from the list of sessions to meet your own individual learning needs.
- Register and receive course confirmation via email and begin.
- Complete content working at your own pace, on your own schedule coming in and out of the online classroom as your time allows.
- 30 days to complete each Session.
- Interact with faculty as needed electronically.
- Print off/download your CE award upon completion of the content.
Sessions / Topics in this Series
Care Coordination for Different Settings
Acute Care Transitions (3 CE)
This session discusses the care coordination issues, implementation and gaps in Acute Care settings. Nurses’ roles in facilitating effective care transitions will be described along with best practices for effective patient discharge. Mary Naylor’s ‘Transitional Care Model’ will be examined, including a description of the role of the RN and NP in acute care transitions. The Center for Medicare and Medicaid Services (CMS) payment rules specific to transitional care will be explained.
Primary Care and Patient Centered Medical Homes (3 CE)
Transformation of the U.S. Healthcare system includes a shift away from acute care with a focus on primary care. This will require RNs to have a better understanding of primary care including care coordination issues, implementations and gaps. Nurse Care Coordination models will be described including the essential functions, roles and practice of nurses embedded in Patient Centered Medical Homes. National Committee for Quality Assurance (NCQA) criteria for medical home certification including requirements for care coordination will be explained.
Long Term Services and Supports (3 CE)
Effective care coordination requires RNs to strengthen their understanding of Long Term Care Services and Supports. In this session Long Term Care systems are reviewed and care coordination issues, implementation and gaps discussed. Housing progression for changing needs in aging is described. Evidence related to emerging nurse practice models that move beyond traditional options will be examined. Local and national polices that support or hinder new LTSS possibilities are reviewed including current and emerging payment models.
Care Coordination for Different Populations
Family Caregiver Support (3 CE)
As the U.S. healthcare system transitions to a community based, person and family centered model, many patients are being discharged directly from acute care settings to their homes or other community based private settings. In this session, family caregiver demographics and training/support needs will be discussed. Patients now often rely on family or informal caregivers to ensure safe transitions, and implement complex medical care formerly provided be nurses; including, provision of medical treatments, medication management, multiple appointments scheduling and knowledge of available resources. Learn how RNs can provide support for Caregivers, and understand the burdens a caregiver faces when providing care for a loved one at home. Financial realities and policies to support these changes are explained. Validated caregiver assessment tools and caregiver video training options are recommended.
American Indian/Alaska Native Populations – An Overview of the Indian Healthcare System (3 CE — Coming Soon!)
In this session, an overview of the Indian Health Service (IHS) including federal funding sources and a comparison of service access and availability between IHS and the private sector will be discussed. Social determinants of health and population health disparities specific to American Indian/Alaska Natives (AI/AN) as it impacts individuals, families and tribes are described. Nursing implications for coordinating referrals for financial, medical and other health needs for AI/AN people both in and outside of the IHS system are emphasized including resources to support RN understanding of the unique care coordination needs of this population.
U.S. Veterans in the VA and/or Private Sector (4 CE — Coming Soon!)
Effective Care Coordination for Veterans requires RNs to understand the unique features of the Veterans Health Administration (VHA), financial and funding differences and similarities from public and private health care delivery models. In this session, RNs will be able to learn about the unique demographics and characteristics of the VA patient populations and service delivery systems. The Mission Act (formerly the Veterans Choice Program), VA Quality Star Ratings will be explained. Strategies for reducing care fragmentation and improving veteran satisfaction with care are described.
Older Adults (4 CE — Coming Soon!)
Every day in the U.S. 10,000 adults turn age 65 reminding nurses that the population they most often care for is rapidly growing older. Many older adults are now challenged with managing both chronic health conditions and variations of aging resulting in a changing health status and more frequent use of healthcare resources. Key to effective care coordination includes nursing’s assessment of older adults for age related changes and potential impact on overall health status and outcomes. This session will focus specifically on increasing nurses understanding of normal changes that commonly occur with aging and identification of physical, emotional, cognitive and sociologic changes that may increase health risk for older adults. Evidence based assessment tools and interventions that nurses can use will be recommended. Health promotion including coping and adaptive strategies will be discussed.
Rural (3 CE — Coming Soon!)
In this session the demographics of rural populations across the United States are described and the differences in care coordination between urban/suburban and Rural America are discussed. Care coordination strategies designed to meet patient needs and preferences in the delivery of high-quality, high-value health care in rural settings are introduced and best practices to develop RN care coordination services are recommended.