Advanced Care Coordination knowledge and skills are essential components of practice for all RNs across practice settings. Registered Nurses prepared in advanced care coordinator roles work across all care settings from hospital to clinic to home, and are well positioned to connect patients, providers and services to assure that care is coordinated, safe and truly patient centered.
A distinction of nurses is their ability to individualize care for each person they encounter. Nurses are able to generate individualized care plans that take into account the patient’s emotions, values and beliefs, relationships, self-awareness, self-concept, and cognitive and strength abilities. Advanced Care Coordinators develop face to face partnerships with patients most in need of targeted care, including high risk patients and those who utilize expensive services. This role differs significantly from traditional case manager roles that are focused on phone banks, utilization review and resource management.
Elements of the advanced care coordinator role include enhanced discharge planning, holistic assessment of social determinants of health, improved internal patient transfers and external transfers to other facilities or to the patient home, and knowledge of financial and systems changes that impact patient care options.