Assessment 1: Comprehensive Needs Assessment

MSN6610 Vila Health™ Activity

The Nurse’s Role in Care Coordination

· Introduction

· Care Coordinator Orientation

· Orientation Email

· Orientation Interviews

· Patient Meeting Email

· Patient Meeting

· Patient Meeting Debrief

· Conclusion

· Credits

Introduction

Care coordination is one of the fastest growing and evolving trends in the nursing field. In order to be an effective care coordinator, it is important to understand the roles that case managers and other care coordination team members play in a health care setting. It is also valuable to understand how these roles have evolved—and continue to evolve— over time. In this activity, you will learn more about the role of care coordination in an acute care setting.

After completing the activity, you will be prepared to:

· Summarize the roles that case managers and other team members play in care coordination.

· Contextualize care coordination and today's care coordination trends historically.

Care Coordinator Orientation

Congratulations! You have been just hired as a case management intern in the Case Coordination Department at St. Anthony Medical Center. Located in Minneapolis, St. Anthony is a 120-bed hospital in the Vila Health system, which operates facilities in several Midwest states. The Care Coordination Department manages patient cases throughout the entire hospital.

Since it's your first day, your first task is to get oriented. Your preceptor will help you get started. To learn more about the roles that care coordinators play in nursing, you'll be talking with experienced case managers, social workers, and other members of the team. You'll also sit in on a coordination planning meeting.

Orientation Email

Email

From: Denise McGladrey Subject: Your first day

Welcome to St. Anthony! We're so glad to have you on the Care Coordination team. As you know, I am going to be your preceptor. My job is to help you transition into your new role as case management intern and to offer you support. You should feel free to come to me with questions.

I have several meetings today, so I won't be able to meet with you until this afternoon. In the meantime, since this is your first day, I want you to learn more about your role by talking with some of the people with whom you'll be collaborating. I'd like for you to ask them questions about the case management role and the skills you'll need to be successful. Most of the people you'll be talking to have a good deal of experience, so I'd also like for you to ask questions about how the field has evolved over the years.

I've gone ahead and scheduled two interviews with you: one with Vicki Vasquez, who, as you know, is the Director of Case Management here at SAMC. The other interview will be with Samantha Rockwell, an experienced social worker who you'll be coordinating with quite a bit in the near future. You'll also have the opportunity to schedule interviews with your choice of a number of other team members.

I'll be catching up with you later. Have a great day!

--Denise

Orientation Interviews

Content of this section depends on choices made during the scenario. Complete at least one attempt of the scenario to see your choices reflected here.

Patient Meeting Email

Email

From: Denise McGladrey Subject: Patient meeting

I see you've been busy meeting with team members to learn more about care coordination roles and trends. Thank you so much for doing that!

I have another task for you that will help you get oriented. There's going to be a meeting this afternoon to discuss care coordination strategies for a patient. Here's the background: a 79-year-old man named Fred Decker was seen here two weeks ago with a badly infected toe. After the infection cleared up, he was sent home with instructions. Unfortunately, he and his family weren't able to follow the instructions, and he returned to the hospital three days later with an infection that was even worse—and now he has sepsis. As you know, that's a serious red flag. Care coordinators need to be seriously concerned with readmission rates, as these reflect poorly on the hospital and impact our ability to be reimbursed by Medicare.

Mr. Decker is responding well to antibiotics, thankfully. This afternoon, several members of the team are having a meeting to discuss his care.

Here's what I want you to do. Go to the meeting, and just listen. At future meetings throughout your internship, you'll offer your feedback, but for today, I just want you to be a "fly on the wall." Afterwards, you'll meet with me. I'll ask you some questions about the meeting and provide you with some feedback.

Thanks for all your hard work!

Denise

Patient Meeting

Content of this section depends on choices made during the scenario. Complete at least one attempt of the scenario to see your choices reflected here.

Patient Meeting Debrief

Content of this section depends on choices made during the scenario. Complete at least one attempt of the scenario to see your choices reflected here.

Conclusion

You have completed the Nurse's Role in Care Coordination activity. Now that you have spent your first day on the job at St. Anthony Medical Center, you should have a better idea of the role that case managers and other team members play in care coordination. You should also have a better understanding of care coordination trends, and how these trends can be contextualized historically.

Credits

Subject Matter Expert: Marie-Elena Barry, DNP, RN

Interactive Design: Anthony Willow

Interactive Developer: Peter Hentges

Instructional Design: Tina Houareau

Media Instructional Design: Naomi Rockler-Gladen

Project Management: Nakeela Hall

Licensed under a Creative Commons Attribution 3.0 License.