Advancing Nursing Practice in Care Coordination and Transition Management

April 1, 2021
April 1, 2021

This blog post is based on a recent Webinar with Dr. Beth Ann Swan, professor at the Jefferson College of Nursing at Thomas Jefferson University.

In the nearly eight years since the landmark IOM Report, "The Future of Nursing: Leading Change, Advancing Health" numerous studies have followed up with focused and actionable recommendations for nursing education and practice. In 2015, IOM reiterated th+e need to continue developing a registered nurse workforce that practices to the full extent of their education and participates as full partners with the interprofessional care team.

Nursing’s Role in Fixing America’s Fragmented Healthcare System

Our healthcare system has grown increasingly fragmented. Individuals with chronic conditions often experience unnecessary service use, receive conflicting advice from multiple providers, have difficulty with service access, and struggle with out-of-pocket expenses. Their care requires time-consuming processes such as comprehensive history taking, counseling, medication reconciliation, and psychosocial intervention. As a result, care providers must consider where individuals came from and where they are going. They must prepare these individuals and their families for the full continuum of care, not just the single setting.

Considering that there are approximately 3.7 million nurses in the United States and registered nurses attend over 50% of outpatient visits, they are poised to play an essential role in ensuring quality and continuity of care delivery in the face of this fragmentation.

Transitions Can Follow Many Tracks

As we think about this paradigm shift for nursing practice, the idealized design may seem linear. It is not. We should view a person’s continuum of care as a railroad switching station. The continuum is not a straight track, but rather multiple tracks with many options. This is the new rationale for acute care and ambulatory care nurses coming together to create new models of care.

Given the multiple tracks from inpatient to outpatient and even to community settings, there is a need for care coordination and management of the transition between providers and settings of care. Unfortunately, this coordination is often episodic or overlooked, and it tends to be organized around a specialty, not primary care. Further, transitions frequently occur with no point person held accountable for coordination.

Changing the Culture

Nurses can change this culture of single-setting handoff by communicating: “Yes, you’re here today, but my colleagues have given me a better picture of where you are in your transition. Because of our time together and my commitment to your care coordination and managing your transition, I now have a better appreciation of where you’re going and who’s going to be taking care of you there.” Under the old paradigm, the message might have been, “This completes your visit today, and thanks for coming. Goodbye.”

The registered nurse is now invested in what’s happening to that person when they’re out of sight. This represents a major change in the way we think about how we provide care.

What Will You Do to Advance Your Practice?

I challenge nurses to identify three things you will do tomorrow and the next day at your organization to further the agenda of RNs practicing across the continuum of care. Keep these things on your to-do list and hit the ground running. We need to feel the urgency to change the paradigms from thinking about care in separate settings to considering care delivery across the continuum. In the words of George Bernard Shaw, “People who say it cannot be done should not interrupt those who are doing it.”

To listen to the recording, visit here. For more information, visit