Each year, the ONS Board of Directors sponsors a session at the ONS Annual Congress on a particularly important, high-impact topic. During a session at the 42nd Annual Congress in Denver, CO, the leadership chose the up-and-coming nursing role of care coordination and transition management (CCTM).

“It is catching on throughout the country, because there are so many people who need it,” Sheila Haas, PhD, RN, FAAN, nursing research consultant at Northwestern Memorial Hospital, said. Health care in the United States is becoming more specialized, Haas said, and patients are also becoming more complex, with chronic and multiple diseases and comorbidities, both physical and psychological. Furthermore, she said, “the social determinants of health care—mental health, addiction, food deserts—we are not designed to cope with them.”

Primary care is where most care is occuring, she said, so an emphasis is starting to be placed on RNs and advanced practice nurses (APNs) working in primary care but having double or triple certifications in subspecialties, such as cancer. As healthcare delivery continues to shift from inpatient to outpatient and community settings, care coordination and transitions are becoming “overlooked [and] episodic,” Haas said, “with no one accountable.”

To address the problem, the American Academy of Ambulatory Care Nursing launched an initiative led by Haas and other nurse leaders, collaborating with schools of nursing, to develop national, evidence-based dimensions and competencies for the CCTM nursing role. The team searched literature in many fields, not just nursing; applied the Quality and Safety Education for Nurses framework; used project-management techniques and logic modeling; and held online focus groups with nurse leaders from varied settings.

The initiative determined that an RN or APN practicing CCTM should focus on the following domains and competencies:

  • Teamwork and collaboration (e.g., huddles, interprofessional reporting, care planning)
  • Establishing ongoing relationships through education and engagement
  • Population health management, using evidence‐based population guidelines
  • Patient‐centered care planning (i.e., evidence-based interventions modified as needed based on patient values, preferences, and goals)
  • Assessment, which may involve home visits at least initially, and surveillance, which may involve the use of smartphones, technology such as Skype, patient portals, community resources for blood pressure monitoring, etc.
  • Coaching and counseling
  • Support for self-management
  • Cross-setting communication and transition management
  • Advocacy (e.g., insurance coverage, medications, equipment, proper living conditions)
  • Nursing process (i.e., documentation in the electronic health record of assessments, interventions, and outcomes, coded in standardized language, so that effectiveness can be evaluated)

Implementation of CCTM is expected to provide evidence of nurses’ contribution to care outcomes, standardize communication to ease patients’ transitions across providers and settings, and improve focus on the importance of using evidence-based population health management for defined populations prior to individualizing care.

Haas acknowledged that certain challenges lie ahead if CCTM is to be fully integrated into the care of complex, chronically ill patients in ambulatory care settings. Among them, job descriptions must incorporate the competencies, staffing models and teams must be reconfigured to include and support the role, and education and evaluation methods must be developed to foster the intent of the competencies in and across professions. Those steps will help to create an environment that supports the role both physically and culturally. In addition, communication tools should be developed and standardized to facilitate interprofessional communication. And finally, methods must be developed to track and measure the impact and value of CCTM.

Visit the AAACN website for more information about CCTM, including resources, online courses, and details about the certification program.

This session was sponsored by the ONS Board of Directors.

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