Healthcare delivery reform has been an ongoing topic for leaders in the healthcare industry. This has been one of the highest priorities for those who are trying to improve and reform healthcare across the continuum, from the individual providers to the large government agencies. What can nursing leaders do to help accomplish this mission? They can develop solid care coordination models to improve the healthcare delivery system. Care coordination has been defined by the Agency for Healthcare Research and Quality as the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care in order to facilitate the appropriate delivery of health care services. Care coordination can be the answer to eliminating fragmentation within healthcare.

Nurses are the gateway, as healthcare change agents, and can achieve positive change by adopting care coordination into their practice. The successful coordination of care practices incorporates six crucial components; frequent face-to-face contact with patients, opportunities for face-to-face contact with patients and physicians, strong patient education rooted in behavioral change theory, comprehensive management of care setting transitions, care coordinators as a communication hub, and comprehensive medication management.

Frequent Face-to-Face Contact with Patients

Frequent face-to-face contact with patients has been demonstrated to improve healthcare outcomes. This allows for opportunities to educate patients consistently and comprehensively. Learning theories suggest that people absorb, process, and retain knowledge differently. Frequent face-to-face contact allows for all patients to retain the necessary information needed to make positive patient-centric changes. It allows for information clarification throughout the trajectory of chronic illness. For the staff nurse, this can function as “strong patient education” rooted in behavioral change theory.

Frequent Face-to-Face Contact with Patient’s Physicians

Frequent fact-to-face contact with patient’s physicians allows for the optimization of medications, lab tests, and necessary procedures. Nurses can be change agents by advocating for necessary work ups and monitoring drug efficacy. Nurses know their patients the best, and by having frequent contact, they have the ability to comprehensively manage patients, whether it is in mental health, primary care, or floor nursing.

Behavioral Change Theory

Motivational interviewing is an evidenced based, peer reviewed study that has shown promising results in managing disease. This style of approach is patient-centric and can be tailored to the patient’s needs. Patients may not adhere to medications because of unwanted side effects, memory problems, trouble seeing, etc. This is where a nurse can function as a change agent by brainstorming ideas that may help change non-adherent patients. Practicing trauma informed care is another peer reviewed, evidence based alternative for optimizing healthcare. Approximately 70% of adults have a PTSD-related traumatic event that occurs in their lifetime. This can alter neurotransmitters and can have a negative impact on developing and managing illnesses.

Care Setting Transitions

Care setting transitions have been identified as “any movement of a patient,” including discharge. Transitioning of care is notoriously the time when patients can be lost in healthcare. Lack of communication, ineffective education, age-related decline, and accountability have all been identified as root causes for less than adequate outcomes. Nurses can function as the “communication hub” for their patients. Knowing that transitions of care can be a vulnerable time, nurses can optimize outcomes by following these guidelines: continuous and effective education rooted in behavioral change theory, strong effective communication, and holding themselves accountable.