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Issues up close

The American Nurses Association (ANA) has long recognized the primary role of registered nurses (RNs) in care coordination. Nurses have always included care coordination as part of their key competencies and counted it as a core professional standard. Now, during the healthcare transformation in light of the Affordable Care Act, it is more important than ever before to formally acknowledge and support nurses’ pivotal role in patient-centered care coordination.

ANA believes healthcare organizations must recognize nurses’ unique role as care coordinators. ANA further believes that care coordination must be recognized as a distinct part of patient care and it must be fully reimbursed.

“Care coordination has always been a part of nursing care. It’s long overdue that this nursing service is highlighted, accounted, and paid for, just like other essential healthcare services that a patient receives,” said ANA President Karen A. Daley, PhD, MPH, RN, FAAN. “Patients know that nurses are coordinating their care. They want to better understand their plan of care and be assured of continuity.”

The Institute of Medicine’s 2003 report, Priority Areas for National Action: Transforming Health Care Quality, notes that without efficient and effective care coordination, costs increase, as does the potential for drug interactions, medical error, and duplication of tests and services. This is especially true when patients are seen by many different care providers over a long period of treatment. Without effective care coordination, it is difficult for patients and providers to optimize treatment and ensure that the patient receives the most appropriate care for his or her condition over time and between different providers.

ANA released a new position statement on June 11, 2012 that reinforces nurses’ role in care coordination and outlines what ANA believes is the correct approach to patient-centered care coordination across patient populations and all healthcare settings. In the position statement, ANA states that care coordination functions must be defined, measured, and documented within the structures and financial operations of healthcare pro­viders to create appropriate incentives for ensuring that this integral function is performed across the care continuum. As it stands, care coordination is at times more of an afterthought, financially, or is bundled in the overall cost structure. This approach is outdated and must be changed to ensure that care coordination—and nurses’ role in it—is appropriately recognized, optimized, and reimbursed.

Indeed, the current system of fragmented care serves to discourage care coordination across disciplines, providers, and care settings. There is little reason to believe that without significant financial incentives to specifically promote care coordination the system will change on its own to encourage better collaboration and efficiencies across the care continuum.

It is especially important to address these barriers in light of findings by several reports and studies demonstrating the many benefits of quality care coordination. These benefits include the following:

  • reductions in emergency department visits
  • decreases in medication costs and reduced inpatient charges
  • reduced overall charges
  • significant increases in survival with fewer readmissions
  • lower total annual Medicare costs for those beneficiaries participating in pilot projects compared to control groups
  • increased patient confidence in the ability to self-manage their care
  • improved quality of care and clinical outcomes
  • increased safety of older adults during transition from an acute care setting to home
  • improved patient satisfaction overall.

Above all, care coordination should be based on the needs and preferences of the healthcare consumer and the consumer’s family, with the goal of providing the most appropriate care for that patient’s situation. Nurses have a primary role in ensuring high-quality patient care and satisfaction; this is especially true in specialized patient-care settings that involve high-risk populations, but applies in almost all healthcare settings.

“The nurse’s role is to ensure that essential services for the patient don’t fall through the cracks, which can easily happen in our current fragmented system of care where good communication between healthcare pro­viders or settings is often lacking,” Daley said.

Nursing takes an integrated, holistic approach to care coordination that maximizes quality, safety, and efficiency in care by clearly designating RNs as taking the lead in patient care coordination in a multidisciplinary setting. Indeed, nurses are particularly suited for this task: Not only is it is built into their scope of practice, but no other healthcare professional has the opportunity to regularly influence care at every level of practice setting and in such a wide range of patient populations.

Care coordination and nurses’ scope of practice

Care coordination across settings and populations is outlined clearly in ANA’s Nursing: Scope and Standards of Practice document as part of the RN’s professional scope of practice. In the document, the nurse’s role as care coordinator is clearly defined and described as performing the following functions:

  • organization of care plan components.
  • management of healthcare consumers’ care to maximize independence and quality of life
  • assistance to healthcare consumers in identifying care options
  • communication with the healthcare consumer, family, and members of the healthcare system, especially during transitions in care
  • advocacy for delivery of dignified care by the interprofessional team
  • documentation of coordination of care.

It is important to note that the duties outlined in the scope and standards are not delegated tasks, but rather form an integral part of the nurse’s independent practice. Nurses are expected to use their experience, skills, and education to make informed decisions on care coordination that take into account the patient’s needs and preferences and ensure quality care throughout.

ANA’s Code of Ethics for Nurses reinforces the nurse’s role as patient advocate. The Code of Ethics states that nurses are expected to serve as a primary patient advocate, which clearly includes care coordination and recognizes nurses’ responsibility to facilitate interprofessional collaboration to produce optimal patient care outcomes.

It is important that care coordination be a required part of nursing education at all levels, and that all nurses understand their pivotal role in maintaining the quality and efficacy of care throughout their patients’ healthcare journey. In agreement with the Institute of Medicine’s 2011 report, The Future of Nursing: Leading Change, Advancing Health, ANA advocates that care coordination education be a requirement of prelicensure and that it be included in all master’s and doctoral nursing education. ANA further believes that it is imperative that the concept of care coordination be stressed across all healthcare disciplines, to foster an environment that breaks down interdisciplinary barriers to coordinated, patient-centered care.

Additionally, more work needs to be done to examine nursing’s role in complex care coordination and to visualize how nursing can advance and refine its role as primary care coordinators as health care continues to transform in coming years. By looking forward and anticipating changes, including new technological, procedural, and scientific advances, nurses can solidify their position as the linchpins in care coordination and maximize the impact they have on the future of health care. It is imperative that nurses take the lead in developing the strategies for and future direction of coordinating care.

Where do we go from here?

ANA recently met with Centers for Medicare & Medicaid Services (CMS) Acting Administrator Marilyn Tavenner to discuss the importance of properly recognizing RNs for their essential role in providing care coordination and improving financial incentives to encourage providers, payers, and the healthcare system as a whole to better integrate care coordination into patient care. ANA continues to work with leaders in government, the healthcare sector, and the public to stress the importance of these initiatives and work toward systemic reforms that will encourage the adoption of nurse-led care coordination as part of the basic level of expected care.

In 2011, ANA submitted comments on proposed CMS rules for Medicare Accountable Care Organizations (ACOs) that subsequently positively influenced the final adopted rules. ANA, while pleased with some gains made on this front for both nurses and patients, notes that there is more to be done in the ACO arena in terms of coordinated care, and continues to pursue changes to the rules to encourage nurse-led coordinated care in ACOs.

Much is to be gained from providing healthcare consumers the most efficient, highest quality, and most coordinated care available. ANA recommends the following steps to move health care in the right direction in terms of achieving that goal:

  • Conduct more studies on how to improve quality measures and best practices that encourage high-quality care coordination.
  • Stress the importance of care coordination and interprofessional, team-based care and ingrain it in the educational model for nurses at all levels, from first-year nursing students to postgraduate nurse scholars.
  • Identify and implement care coordination opportunities that encourage nurse-led approaches to care coordination.
  • Explain the importance of care coordination and encourage the participation of patients, their families, and the public in achieving high-quality outcomes as a result of good care coordination.

To learn much more about ANA’s approach to nurse-led care coordination, go to www.nursingworld.org/
care-coordination, where you can find ANA’s position statement “Care Coordination and Nursing’s Essential Role.” In addition, the website includes “The Value of Nursing Care Coordination,” an examination of the current literature on the economic and patient-care quality benefits of care coordination, especially that provided by nurses, as well as many other resources and information.

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