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The Future of Nursing: Leading Change, Advancing Health
Another superlative example of care coordination is On Lok Senior Health Services for older adults living in San Francisco. For over 30 years, On Lok has used multidisciplinary teams, electronic medical records, capitated payment, and a full range of services (including transportation, housing, meals, adult day health services, and geriatric aides who make frequent home visits) to provide seamless transitions for nursing home-eligible frail elders at lower cost than usual care. On Lok became the model for similar institutions around the Unitd States through the Program of All-Inclusive Care for the Elderly (PACE) (Bodenheimer, 1999).
Another care coordination model is Tom Bodenheimer’s “teamlet” (Bodenheimer and Laing, 2007), dyads that are a subset of the larger health care team and comprised of a physician and, ideally, an experienced nurse or an APN. Patients enter “an expanded encounter,” in which pre-, post-, and between-visit care is continually monitored and coordinated by the nurse. Ingredients for success include making sure the patient understands advice and direction and agrees with the plan of care; communicating and interpreting laboratory and other diagnostic tests, and continually looping information between the patient and family, the physician, other care providers such as clinical pharmacists and allied health. Bodenheimer notes that ideally the coach would be an RN or an advanced practice nurse, but in their absence, a medical assistant could be trained for the role.
Thus, the role of care coordinator as patient advocate, communicator, assessor, and intervener, ideally suited to what nurses do best, presents a huge opportunity for nursing education. But, as implied by Bodenheimer, the nursing profession will be bypassed if nurses fail to seize the opportunity. To do so, however, requires that nursing school curricula incorporate not just the knowledge underlying the competencies of the role but convey the importance of the role to students by threading the concept and competencies of care coordination throughout the curricula. As already mentioned, most nursing curricula currently teach compartmentally, not across systems. Courses, particularly in the baccalaureate program where attitudes about nursing and nursing care are first formed, focus on content and skills in specific discrete clinical settings. Faculty generally teach within, not across, settings of care. Often the master’s level Clinical Nurse Specialist program is the only track with a course or parts of courses that address care transitions and care coordination, and this content may be confused with case management, the latter being a more limited concept usually applied to containing costs within reimbursement systems.
Interprofessional education discussed above will by itself, improve graduates’ competence in care coordination because many of the competencies students learn in IPE are relevant. However, there is a body of knowledge and sets of skills, attitudes, and role-related behaviors specific to care coordination that should be integrated throughout the levels of nursing education rather than confined to episodic IPE training.