Your preceptor has been observing your effectiveness as a care coordinator and recognizes the importance of educating other staff nurses in care coordination. Consequently, she has asked you to develop a presentation for your colleagues on care coordination basics. By providing them with basic information about the care coordination process, you will assist them in taking on an expanded role in helping to manage the care coordination process and improve patient outcomes in your community care center.
The Core Process: The 5 A's
As staff nurses, our role in care coordination focuses heavily on Assessment, Communication, and Advocacy. We can simplify the process into the following steps:
Assess Needs:
Identify the patient's immediate health needs, social determinants of health (SDOH) (e.g., housing, transportation, food security), and their readiness for self-management.
Nurse Action: Use screening tools for depression, literacy, and social needs.
Align Resources:
Match the patient's needs to the available internal (e.g., social worker, nutritionist) and external (e.g., home health, community resources) services.
Nurse Action: Consult with the patient to prioritize the most impactful resource.
Action Plan Development:
Create a simple, documented plan that specifies the roles of the patient, family, and all providers. This plan should be SMART (Specific, Measurable, Achievable, Relevant, Time-bound).
Nurse Action: Ensure the patient understands and agrees to the next steps (e.g., "You will call the specialist by Friday").
Assure Follow-Up & Linkage:
Confirm that the patient successfully connected with the next level of care (e.g., verifying a specialist appointment was kept or medication was picked up). This is often the weakest link in the process.