Care Coordination: Roles of Registered Nurses Across the Care Continuum

Beth Ann Swan, PhD, CRNP, FAAN; Sheila Haas, PhD, RN, FAAN; Anne T. Jessie

Disclosures

Nurs Econ. 2019;37(6):317-323. 

In This Article

Abstract and Introduction

Abstract

Lack of coordination leads to health care that is fragmented, inconsistent, and poorly planned. Conversely, effective care coordination supports achieving the Quadruple Aim. Care coordination, roles of RNs in care coordination, and implications for healthcare delivery are explored.

Introduction

Six in ten adults in the United States have a chronic illness and four in ten adults have two or more chronic illnesses. Chronic diseases are the leading cause of death and disability and leading drivers of the nation's $3.3 trillion in annual healthcare costs (National Center for Chronic Disease Prevention and Health Promotion, 2019). Concurrently, the incidence and prevalence of chronic health conditions has increased, with conditions such as diabetes, heart disease, cancer, hypertension, stroke, arthritis, obesity, renal disease, and respiratory diseases leading the way as the most common causes of illness, long-term disability, reduced quality of life, and death (National Center for Chronic Disease Prevention and Health Promotion, 2019; Raghupathi & Raghupathi, 2018). With such a large chronically ill population, the need for improved care is obvious. Individuals with chronic diseases generally receive care by more than one provider in more than one setting, and, too often, their care is not coordinated across the continuum. Within this care environment, medical decision-making occurs in a vacuum without complete information about an individual's condition, health history, medications ordered, care managed, or services rendered. In addition, no one facility is officially responsible and accountable for the individual, meaning no one practitioner takes the lead in making the plan and next steps in care clear. Instead, the job of coordinating care is transferred from the professionals to individuals and their families who are often unprepared to manage the task.

The lack of coordination leads to care that is fragmented, inconsistent, and poorly planned. Medical errors, duplication of tests, and paper shuffling can occur, with results ranging from inconvenient to life-threatening. The lack of coordinated care can also lead to unnecessary emergency room visits and hospitalizations, avoidable readmissions, and excessive resource use causing billions of dollars in wasteful spending each year. In fact, researchers estimate that $25 to $45 billion is spent on avoidable complications and unnecessary hospital readmissions (Burton, 2012).

Conversely, effective care coordination supports achieving the Quadruple Aim: improving the care experience for individuals, improving individual health, improving the work life of healthcare providers, and reducing costs (Bodenheimer & Sinsky, 2014). One essential component of effective care coordination is the role of registered nurses (RNs).

The nursing profession has a long history of caring for individuals in a holistic manner, integrating traditional health care with person-centered approaches that are focused on health and healing; and integrating and incorporating interventions from a variety of healthcare disciplines. Across settings of care, RNs provide care that is based on the individual's values, goals, preferences, and specific care needs. RNs lead care coordination programs and interprofessional teams across diverse acute, post-acute, and community-based care settings, playing pivotal roles in the design and implementation of new care delivery models such as behavioral and physical health integration, Patient-Centered Medical Homes (PCMHs), Accountable Care Organizations (ACOs), and emerging payer-based care delivery initiatives. Connecting and integrating individuals with providers and services, RNs work to optimize individuals' clinical and functional status, as well as self-care management with the goal of improving outcomes and containing healthcare costs. RN-led care coordination is often aligned with quality, safety, payer, and healthcare reform initiatives, placing RNs in a role that is central to healthcare delivery across the care continuum. Care coordination, the roles of RNs in care coordination, and implications for healthcare delivery will be explored.

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