This document discusses care coordination and its value. It defines care coordination as promoting quality, safety and efficiency in care through improved healthcare outcomes using a holistic and patient-centered approach. Registered nurses are central to organizing patient-centered care and enhancing value through quality outcomes and efficiencies. Care coordination can reduce hospital-acquired conditions, readmissions, costs and improve patient satisfaction. The document outlines various strategies nurses can use to demonstrate the value of care coordination.

1. Maureen Dailey, DSNc, RN, CWOCN
Eileen Shannon Carlson, RN, JD
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2. Care Coordination Definition
“Care coordination promotes greater quality, safety, and
efficiency in care, resulting in improved healthcare
outcomes and is consistent with nursing’s
holistic, patient-centered framework of care. A
knowledgeable healthcare professional deliberately
designated to coordinate care is necessary to effectively
utilize resources within the set of complex health
systems and multiple providers in accordance with
patient and family care needs (McDonald et al., 2011;
O'Malley, Tynan, Cohen, Kemper, & Davis, 2009)” –
ANA’s Policy Statement on Care Coordination, 2012
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3. ANA Scope and Standard of Practice (2010)
Registered Nurses (RN):
 Are central to organizing the patient-centered care
experience, among diverse populations and across
settings.
 Influence care at every level
 Utilize CC competencies (ANA, 2010,p. 40) and
processes as a central aspect of professional practice
 Enhance care value by contributions to successful
quality outcomes and increased efficiencies.
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4. National Quality Strategy (HHS)
 Guide Star for Improving Healthcare Quality
 Updated Annually
 Informed by the National Priorities Partnership (NPP)
– ANA is an NPP Partner
 Focuses Needed Action for Performance Improvement
 Web link:
http://www.ahrq.gov/workingforquality/index.html
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5. New Payment Environment
 Health Care Reform – Accountable Care Act
 Pay for Reporting – Transparent Quality
 Hospital Compare and other settings
 Pay for Quality & Value -
 Results Focus – NQS Tri-part National Aim:
 Improve Quality (e.g., improve safety)
 Improve Health (e.g., prevention)
 Reduce Excessive cost (e.g., readmissions)
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6. Hospital Acquired Conditions
 Partnership for Patients (Pf) - Campaign in the CMMI
 40 % Reduction in Hospital Acquired Conditions (HAC)
 Falls, Pressure Ulcers & Hospital Acquired Infections
 Adverse Medication Events
 20% Reduction in Avoidable Rehospitalization
 ANA is a PfP Partner
 PfP Hospital Engagement Networks:
 Charged with reaching goals
 ANA’s National Database of Nursing Quality
Indicators® (NDNQI®) provides national comparison
data
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7. Value of Nursing Care Coordination (CC)
 Reduction of HACs
 Falls with injury
 Pressure Ulcers
 Hospital Acquired Infections (e.g., catheter associated
urinary tract infections – CAUTI, Central Line
Associated Infections – CLABSI)
 Reduction in Medication Errors
 Reduction in Maternity Harm
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8. Value of Nursing Care Coordination (CC)
 Reduction of Hospital Readmissions
 30 day Readmission (avoidable)
 All Cause
 All Settings (e.g., skilled nursing facilities, home health
etc.)
 Diagnosis Related (e.g., Heart Failure)
 Reduction of Index Admission
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9. Value of Nursing Care Coordination (CC)
Results from the Literature
 Reductions in emergency department visits
 Noticeable decreases in medication costs
 Reduced inpatient charges
 Reduced overall charges
 Average savings per patient
 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 self-managing care
 Improved quality of care
 Increased safety of older adults during transition from an acute care setting to
the home
 Improved clinical outcomes and reduced costs
 Improved patient satisfaction overall
ANA Value of Care Coordination Paper (2012)
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10. Strategies to Demonstrate Value
 NDNQI
 Participate in Unit Data Dashboard Review
(e.g., structure, process, and outcome measures)
 Identify successes & improvement opportunities
 Participate at unit level to improve outcomes (e.g., join skin care
team)
 Identify Contributions to Prevention (e.g., consistent use of
evidence-based tools and practice)
 Contribute to Improved Transitional Care
 Patient/Caregiver Education (include teach back)
 Continuum of Care Collaboration (e.g., team-based collaboration –
consistent education, timely supplies/equipment etc.)
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11. Future Issues For
Nursing Care Coordination
 ANA convening Care Coordination Quality Measures Professional
Issues Panel + Advisory Group .
 No “Nurse Care Coordinator” Certification
 Only for Nurse Case Managers, other types of Care/Case Managers.
 Medicare quality reporting, shared savings programs (ACOs, Hospital
Value Based Purchasing, etc.) – communication, coordination among
health practitioners & facilities essential to success.
 Dual eligible (Medicare & Medicaid) care coordination projects.
 Medicare wants more bundled payments, less “fee for service” (FFS).
 Care coordination helps aging patients remain in home, community.
 Physician shortage shifting work to APRNs & RNs.
 30% of Medicare FFS beneficiaries received services from an APRN in 2011.

12. Resources
Care Coordination and Registered Nurses’ Essential
Role, Position Statement of the American Nurses
Association. www.nursingworld.org/position/care-
coordination.aspx.
The Value of Nursing Care Coordination, White Paper of the
American Nurses Association.
www.nursingworld.org/carecoordinationwhitepaper.
CMS Approves New Codes & Reimbursement for Transitional
Care & Chronic Care Coordination.
www.capitolupdate.org/index.php/2013/01/cms-approves-
new-codes-reimbursement-for-transitional-care-chronic-
care-coordination/.
2013 CPT® Codebook. American Medical Association.
www.ama-assn.org/go/online-catalog.

13. Resources
 Center for Medicare and Medicaid Innovation:
http://innovation.cms.gov/
 Partnership for Patients: http://partnershipforpatients.cms.gov/
 Strong Start: http://innovation.cms.gov/initiatives/strong-start/
 Million Hearts: http://millionhearts.hhs.gov/index.html
 National Priorities Partnership (NPP):
https://www.qualityforum.org/Setting_Priorities/NPP/National_Priori
ties_Partnership.aspx
 Action Teams:
https://www.qualityforum.org/Setting_Priorities/NPP/NPP_Action_Teams
.aspx
 Maternity Action Team
 Readmissions Action Team
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