ADVANCED CARE COORDINATION TRAINING FOR NURSES
- THE EMERGENCE OF CONTEMPORARY RN CASE MANAGER & ADVANCED CARE COORDINATION ROLES
- DIFFERENTIATING THE ROLES
- RN CHARACTERISTICS FOR ROLE SUCCESS
- SPECIALIZED KNOWLEDGE REQUIRED
Kelly Kruse Nelles, RN, APRN-BC, MS
(608) 437-6035 (CST)
Mary Jo Borden RN APRN-BC CCM MSN
Nurses prepared for Contemporary RN Case Manager and Advanced Care Coordination roles bring expertise and valuable perspectives about community health, quality, safety, patient experience, workforce development and financial stewardship. Nurses on the front lines of care partnered with complex and high risk patients can work with organizational leaders to address challenges and frame opportunities for system changes and improved patient outcomes. Nurses prepared for Contemporary RN Case Manager and Advanced Care Coordination roles are essential to producing high value outcomes. More RNs are needed to fill these contemporary roles, and to develop the future of this specialty area of professional nursing practice.
Since the 2010 passage of the Patient Protection and Affordable Care Act (PPACA) there has been a significant increase in the call for Registered Nurses to practice in case manager, care transitions and care coordination roles in all practice settings. Demonstration projects taking place from the early 1980s to present describe evidence based nurse practice models that have emerged and are being implemented in contemporary practice. The PPACA specifically highlights care coordination via case management as “an essential component of high quality care and is a requirement of both Accountable Care Organizations and Patient Centered Health Care Homes.
Case manager, transitional care nurse, care navigator, care coordinator, complex care managers, health coaches – are just a few of the many titles used to reflect contemporary RN Case Manager and Advanced Care Coordination Practice. Contemporary RN Case Managers and Advanced RN Care Coordinators work in “front line” positions to partner with patients and their caregivers as they move across the healthcare continuum helping to ensure that patients receive the right care at the right time.
Registered Nurses in Contemporary RN Case Manager and Advanced Care Coordination roles partner effectively with patients and their families, engage patients in self-management and health behavior change, positively affect patient self-care practices and decision-making, provide comprehensive assessment and care planning using shared decision making, implement evidence based interventions and advocate for the right care at the right time.
Advanced Care Coordination knowledge and skills are also 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. 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.
Contemporary RN Case Managers 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.
Advanced Care Coordinators and Contemporary RN Case Mangers work collaboratively to prioritize patients in need of specialized care coordination services including case management and care transitions. RNs in both roles also work effectively as contributors to multi-disciplinary care teams.
Nurses practicing in Contemporary RN Case Manager and Advanced Care Coordination positions will be primed for success if they have:
- Strong clinical skills, including a commitment to evidence-based care, problem solving, patient-centered perspective and advocacy
- Foundational understanding of system and policy changes including accountable care organizations, patient-centered medical homes, emerging payment models and population health
- Ability to manage patient complexity and multiple patients with diverse needs in acute, community or home situations
- Commitment to continuous quality improvement, value in services provided and embracing change in a team-based practice environment
- Comfort with an independent role that includes effective communication skills, health literacy knowledge, and the ability to facilitate relationships and seek consensus among patients and their families and multiple healthcare providers
The complexity of patients with multiple chronic conditions concurrent with the changes occurring within the U.S. healthcare system require specialized knowledge that expands on basic principles of care coordination learned in undergraduate and graduate nursing education. To date, most practice sites provide “in-house” or “on the job training” for RNs hired to fill contemporary roles. Reliance on “on the job training” is simply not enough. Specialized education of RNs as they adopt new contemporary Case Manager and Advanced Care Coordination roles is essential to assure success of both the nurse and the healthcare organization.
Nurses enrolled in our programs will acquire the essential knowledge and skills needed to fill emerging roles, and be prepared to practice to their full potential as members of a multidisciplinary health care team.