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Scope and Standards of Practice for Registered Nurses in Care Coordination and Transition Management

American Academy of Ambulatory Care Nursing East Holly Avenue/Box 56 Pitman, NJ 08071-0056

1-800-AMB-NURS www.aaacn.org

[email protected]

Mission: Advance the art and science of ambulatory care nursing.

eISBN 978-1-940325-25-5

Publication Management by Anthony J. Jannetti, Inc. East Holly Avenue/Box 56 Pitman, NJ 08071-0056

www.ajj.com

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or through any information storage and retrieval system, without the permission of the American Academy of Ambulatory Care Nursing.

American Academy of Ambulatory Care Nursing (AAACN). (2016). Scope and standards of practice for registered nurses in care coordination and transition management. Pitman, NJ: Author.

Scope and Standards of Practice for Registered Nurses in Care Coordination and Transition Management, American Academy of Ambulatory Care Nursing, 2015. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/aspenuniv/detail.action?docID=4768806. Created from aspenuniv on 2020-03-04 04:48:55.

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Scope and Standards Formation Task Force

Cynthia L. Murray, BN, RN-BC (Chair) Ambulatory Care Coordination Southern NJ/Delaware Veterans Health System (VHA)

Shirley Burrow, MSN, RN-BC Supervisor Population Health Care Coordination Piedmont Healthcare, Atlanta, Georgia

Caroline M. Butt, BSN, RN Senior Care Coordinator CCMH Carillion Clinic, Roanoke, Virginia

Eleanor Chapital, MSN, RN-BC Operation Enduring Freedom/Operation Iraqi

Freedom/Operation New Dawn Program Manager Southeast Louisiana Veterans Health System (VHA)

Dawn M. Gerz, MBA, BSN, RN, NEA-BC Assistant Director of Ambulatory Nursing Cleveland Clinic, Cleveland, Ohio

Mary Anne Granger, MSN, RN Clinical Resource Leader, Care Coordination, Ambulatory

Care Management Maricopa Integrated Health Services, Phoenix, Arizona

Frances Gruber, MSN, RN Patient Administrative Service Chief South Texas Veteran Health System (VHA)

Kirsi Hayes, BSN, RN Manager, Care Coordination – East Region Baylor Scott & White Quality Alliance, Dallas, Texas

Lois Stauffer, MSN, RN-BC, CNL Manager, Care Coordination OhioHealth Physician Group, Columbus, Ohio

Advisor

Margaret F. Mastal, PhD, MSN, RN AAACN Past President Retired Alexandria, Virginia

Board Liaisons

Susan M. Paschke, MSN, RN-BC, NEA-BC AAACN Past President Senior Director of Ambulatory Nursing Cleveland Clinic, Cleveland Ohio

Marianne Sherman, MS, RN-BC AAACN Past President Retired Denver, Colorado

Reviewers

Rabon Allen, MSN, RN Rainbow Babies & Children’s Hospital Cleveland, Ohio

Nancy J. Birnbaum, BSN, RN-BC Central Texas Veteran’s Health System (VHA) College Station, Texas

Mary Anne Bord-Hoffman, MN, RN-BC San Jose Outpatient Clinic Palo Alto California Veterans Health System (VHA)

Toyin Lawal, BSN, RN UCLA Health Los Angeles, California

Karen T. McKinsey, MBA, RN-BC San Diego California Veterans Health System (VHA)

Kathy Mertens, MN, MPH, RN UW Medicine – Harborview Medical Center Seattle, Washington

Leslie K. Morris, BSN, RN Texas Children’s Hospital Houston, Texas

Edtrina Moss, MSN, RN-BC, NE-BC Michael E. DeBakey VA Medical Center (VHA) Missouri City, Texas

Wanda C. Richards, BSN, MSM, MPA, RN Retired United States Navy Woodbridge, Virginia

Robbin Weaver MSN, NSII, RN Oak Forest Health Center of Cook County Health &

Hospital Systems Oak Forest, Illinois

MSNCB Reviewers

Julie Alban, MSN, MPH, RN-BC The Villages Outpatient Clinic North Florida/South Georgia Veterans Health System The Villages, Florida

Diane Brookes, BSN, RN, CMSRN VA Maine HealthCare System Augusta, Maine

Christine Chmielewski, MS, CRNP, ANP-BC, CNN-NP Edward J. Filippone, MD, PC & Associates Philadelphia, Pennsylvania Center for Nursing Education and Testing Jersey City, New Jersey

C. Westley Foster, MSN, BA, RN, CMSRN, OCN Banner University Medical Center – Phoenix Campus Phoenix, Arizona Mesa Community College Mesa, Arizona

Margery Garbin, PhD, RN Center for Nursing Education and Testing Jersey City, New Jersey

Darmel Hudson, BSN, RN, CCM First Choice Health Seattle, Washington

Jo Ellen Inman-Puckett, MSN, MBA, RN, CNL, CMSRN, AHN-BC

Carolinas HealthCare System Charlotte, North Carolina

Angelica May, BSN, RN, CCM Elmhurst Memorial Clinic Elmhurst, Illinois

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Scope and Standards of Practice for Registered Nurses in Care Coordination and Transition Management 3

Table of Contents Scope and Standards Formation Task Force ............................................................................................. 2

Introduction ................................................................................................................................................ 5

Scope of Practice for Registered Nurses Care Coordination and Transition Management ...................... 6

Historical Evolution ........................................................................................................................ 6

Definitions of Care Coordination and Transition Management ...................................................... 7

The Chronic Care Model as a Research Guide ............................................................................. 8

The Logic Model as a Connection Tool ......................................................................................... 8

RN-CCTM Model ........................................................................................................................... 8

Defining Characteristics of the RN in the CCTM Role................................................................... 8

Standards of Practice for Registered Nurses in Care Coordination and Transition Management ........... 12

Standard 1: Assessment .......................................................................................................... 13

Standard 2: Nursing Diagnoses ............................................................................................... 14

Standard 3: Outcomes Identification ....................................................................................... 15

Standard 4: Planning ................................................................................................................ 16

Standard 5: Implementation ..................................................................................................... 17

Standard 5a: Coordination of Care ..................................................................... 18

Standard 5b: Health Teaching and Health Promotion ........................................ 19

Standard 5c: Consultation .................................................................................. 20

Standard 6: Evaluation ............................................................................................................. 21

Standard 7: Ethics ................................................................................................................... 22

Standard 8: Education ............................................................................................................. 23

Standard 9: Research and Evidence-Based Practice .............................................................. 24

Standard 10: Performance Improvement ................................................................................... 25

Standard 11: Communication .................................................................................................... 26

Standard 12: Leadership ............................................................................................................ 27

Standard 13: Collaboration ........................................................................................................ 28

Standard 14: Professional Practice Evaluation .......................................................................... 29

Standard 15: Resource Utilization ............................................................................................. 30

Standard 16: Environment ......................................................................................................... 31

Glossary ................................................................................................................................................... 33

References ............................................................................................................................................... 36

Additional Readings ................................................................................................................................. 37

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Scope and Standards of Practice for Registered Nurses in Care Coordination and Transition Management 5

The American Academy of Ambulatory Care Nursing (AAACN), the specialty nursing organization for those practicing in ambulatory care settings, is re- sponsible for establishing and main taining the stan- dards for ambulatory care nursing practice. To fulfill this responsibility, AAACN has published standards for professional ambulatory care nursing since 1987.

The current standards include:

• 2010 – AAACN published the Scope and Standards of Practice for Professional Ambulatory Care Nursing, which addresses the delivery of ambulatory clinical care and administrative nursing in general.

• 2011 – AAACN published the Scope and Standards of Practice for Professional Tele- health Nursing, which specifically addresses professional nursing practice in the subspe- cialty of telehealth.

AAACN embarked on a multi-year journey de- veloping the role of the ambulatory care registered nurse (RN) in care coordination and transition man- agement (CCTM). The RN-CCTM Model was devel- oped, including its dimensions, competencies, core curriculum, and online course. Additionally, AAACN included input from the Academy of Medical-Surgical Nurses (AMSN) to ensure that acute care was incor- porated in this body of work that spans the contin- uum of care (AMSN, 2009, 2012).

This document, Scope and Standards of Prac- tice for Registered Nurses in Care Coordination and Transition Management, is an evolution of AAACN’s body of work and a major step forward for nurses in CCTM roles. It is the first statement of the scope and standards of practice for RNs engaged in CCTM. These roles are part of the vision of the “transformed future of health care” developed by the Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine (IOM). Today’s health care institutions have re- sponded to the requirements of the Affordable Care Act (ACA) of 2010 and are in the process of changing the way health care is delivered. The ACA offers nursing multiple opportunities to facilitate health sys- tems’ improvements and the mechanics of health care delivery (IOM, 2011). CCTM roles focus on com- municating and partnering with other professional health care colleagues across diverse health care settings. These settings include ambulatory care, acute care, post-acute care, long-term care facilities, and diverse community settings.

The actions and competencies within current CCTM roles have been evolving in America over the past 200 years and more intensely over the past 25 years. Yet, there has never been formal identification, specification, and/or publication of the scope and standards of practice. Doing so is a priority if nursing

is to respond to the vision and challenges presented by the IOM report (2011), which includes identifying and defining nurses’ contributions to health care quality, access, and value.

This publication may be used to:

1. Provide guidance for health care institutions and professional staff in regards to the organizational structure and processes (e.g., institutional poli- cies, procedures, role descriptions and compe- tencies) needed to facilitate RN practice in the competent provision of CCTM.

2. Guide the provision of quality nursing care during CCTM processes and activities.

3. Facilitate the development and expansion of the RN practice related to CCTM.

4. Facilitate the evaluation of the RN performance in CCTM activities (e.g., performance appraisals and peer review).

5. Stimulate participation in CCTM research and evidence-based practice.

6. Guide clinical, organizational, and health system performance improvement initiatives that opti- mize patient and/or population outcomes through CCTM (National Committee for Quality Assurance, 2013).

7. Guide ethical practice and patient advocacy in CCTM processes and activities.

This document is the inaugural statement of the scope and standards of practice for CCTM devel- oped and published by AAACN. It includes:

• The historical evolution of modern day CCTM.

• The definitions of CCTM.

• The defining characteristics for the RN practicing in the CCTM role.

• An initial conceptual framework that was adapted from models cited in the care coordina- tion and transition management core curriculum text (Haas, Swan, & Haynes, 2014). The frame- work offers a structure for cataloging and unify- ing the distinct relationships and interactions among the RN, the patient, group and/or popu- lation, the interprofessional health care team, and the resources across the health care contin- uum.

• Sixteen standards for the RN practicing CCTM that address both the clinical dimension and the management dimension.

This document may be used as a tool to ad- vance professional CCTM nursing practice, patient and population health (Halpern & Boulter, 2000), and the performance outcomes of health care institu- tions.

Introduction

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I. Historical Evolution of CCTM CCTM evolved from multiple health care models

that emerged in the United States dating back to the 1800s. Today’s RN-CCTM Model is rooted in care management and innovative hospital and pediatric physician practices that occurred during the latter part of the 1900s. A major influence for today’s model includes changes in the funding system of health care: from reimbursement on a fee-for-service basis to a capitation system (i.e., a prepaid amount of money for each patient over a specified length of time). Still other influences on today’s RN-CCTM Model include the growth of health maintenance or- ganizations (HMOs) and pilot programs of care co- ordination for disabled Medicaid populations. More recently, new legislation has spurred CCTM applica- tions to new types of managed group practices serv- ing the general population. This confluence of phenomena serves as the launch pad for the evi- dence-based professional model available in the Care Coordination and Transition Management Core Curriculum (Haas et al., 2014).

Case Management/Care Management

Case management has a long and rich history whose seeds were planted in the development of so- cial casework in the late 1800s. It came to greater fruition in the United States in the early 1900s in the emerging disciplines of public health, nursing, and social work (Huber, 2000).

By 1990, there were two basic types of models of care management: organizational models and community-based models. The original organiza- tional model was designed by the New England Medical Center. It is an extension of primary nursing methods and focused on the acute care hospital episode. The New England Medical Center model defined case management as a care delivery model and called it nursing case management (Huber, 2000). Over the years, care management has been characterized by the supervision of care or supports, monitoring the utilization patterns of high cost/high use consumers and the employment of the medical model for coordinating authorized services within a single care delivery organization (Abery, Cady, & Simunds, 2005).

The community model emanated from the Carondelet St. Mary’s Community Nursing Network in Arizona. It organized bachelor- and masters-pre- pared nurses as care managers in a nursing HMO. They were the hub of a network of broker services that practiced beyond the acute care episode across the health care continuum. These nurses were

among the first who followed the movement of high- risk clients with chronic health problems from acute care to long-term care in community settings (Huber, 2000).

However, it was the growth of HMOs in the 1990s that precipitated the widespread use of the care management approach throughout health care, insurance, and social service settings (Abery et al., 2005). The physicians and staff learned to work to- gether, a phenomenon that is the basis of care coor- dination and transition management.

Growth of Health Maintenance Organizations (HMOs)

HMOs are prepaid group practices that provide both health care insurance and health care services. They date back to circa 1930 and grew slowly over the following four decades due largely to strong op- position from the medical establishment. However, they attracted enrollees because of low out-of- pocket costs and their emphasis on health promo- tion and illness prevention.

The enactment of the Health Maintenance Or- ganization Act of 1973 (PL 93-222) provided major impetus for HMO growth (Social Security Adminis- tration, 1974). The Act provided funding to assist in establishing and expanding HMOs, superseding state laws that restricted the establishment of pre- paid health plans, and it required employers who had over 25 employees and offered health insurance as a benefit to include an HMO option. “The purpose of the legislation was to stimulate greater competition within healthcare markets by developing outpatient alternative to expensive hospital-based treatment” (National Council on Disability, 2013, p. 1). However, in the following decade, HMOs still grew slowly due to the ongoing opposition of the medical community and HMO regulatory restrictions by individual states. But the escalation of health care costs forced the government to consider new paradigms.

In an innovative move, the government author- ized Medicare payments for kidney dialysis clinics and procedures performed on an outpatient basis. This spurred the formation of physician group prac- tices that specialized in diagnostics, surgery, rehabil- itation, and other services previously performed only in hospitals. The opposition of medicine to managed care plans softened as they began to understand the financial and health benefits of managed care prac- tices.

During the late 1980s and early 1990s, managed care plans were further credited with restricting costs. Their reputation for reducing costs through

Scope of Practice for Registered Nurses in Care Coordination and Transition Management (CCTM)

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Scope and Standards of Practice for Registered Nurses in Care Coordination and Transition Management 7

managed care practices resulted in higher enroll- ments. By 1993, they covered 51% of Americans re- ceiving health insurance through their employer (National Council on Disability, 2013).

With general health care changing and learning new ways to manage care, the government began to focus on the soaring costs of providing health care and improving outcomes for Medicaid populations with disabilities.

Care Coordination for Populations with Disabilities

In the 1990s, Medicaid became highly con- cerned with the poor health outcomes and high costs of caring for children and adults with disabili- ties. State Medicaid agencies began to search for ways to improve care outcomes while reducing costs (Abery et al., 2005).

A combination of funds from the Centers for Medicare and Medicaid Services and private foun- dations established pilot programs in seven states. These pilot programs were community-based agen- cies made up of teams of health care professionals that coordinated the care of Medicaid recipients with disabilities. Each pilot agency developed its own model of care coordination that had unique configu- rations of teams of advanced nurse practitioners, registered nurses, social workers, and unlicensed personnel. All functioned under a medical director. Funding was usually allocated on a capitated basis, but some plans received additional fee-for-service funding for select benefits. Capitation granted care coordinators the option to flex the benefits (i.e., the benefits could be tailored to meet patients’ individual needs) (Palsbo & Mastal, 2006).

In the pilot agencies, the teams consisted of nurses, social workers, and unlicensed personnel who coordinated care. These teams were partners with the enrollees, acting as advocates for benefits to meet each person’s unique needs. They formed the communication link with physicians and other community providers, updating them regarding pa- tients’ status and outcomes. As a result, the pro- grams were successful in reducing costs and improving the health status and quality of life of en- rollees (Palsbo & Mastal, 2006). Several of the pilot agencies became very innovative and made real dif- ferences in enrollees’ lives by minimizing the effects of their chronic disease and enhancing the individ- ual’s ability to improve the management of their health issues. Further, they reduced unnecessary costs and built collaborative bridges among different types of community health care professionals (Mastal, Reardon, & English, 2007).

Embracing Care Coordination: Visions for the Future

In the 21st century, health care costs continued to rise and the numbers of people without health care insurance increased. Further, technology supported the collection of data that enabled providers and

payers to realize that a small percentage of persons with chronic, complex conditions consumed a high proportion of health care resources. It was obvious that chronic conditions are expensive to treat and a major driver of health care spending (Thorpe, 2013). Those who struggle with multiple illnesses combined with social complexities (e.g., mental health, sub- stance abuse, social isolation, and homelessness) find it difficult to navigate the complex, fragmented American health care system (Craig, Eby, & Whitting- ton, 2011).

Additionally, the Affordable Care Act of 2010 in- cludes provisions that require individualized written “plans of care and follow up plans that move with pa- tients longitudinally over time... Care coordination has become an innovative patient-centric interprofes- sional collaborative practice care delivery model that integrates the registered nurse as care coordinator and transition manager” (Haas et al., 2014, p. 3).

RNs have the knowledge and expertise to serve as the pivotal agent of the interprofessional health care team, communicating with and educating pa- tients and caregivers, as well as all stakeholders within the system and across the continuum of care.

II. Definitions of Care Coordination and Transition Management

Although care coordination and transition man- agement are intimately entwined, they are defined separately here to optimize understanding the mean- ing of each and identify how they are related.

Care Coordination Definition

“Care coordination is the deliberate organization of patient care activities between two or more par- ticipants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the mar- shalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care” (McDonald et al., 2007; McDonald et al., 2011, p. 4).

Transition Management Definition

A critical element inherent in care coordination is transition management, which is the ongoing support of patients and their families over time as they navi- gate care and relationships among more than one provider and/or more than one health care setting and/or more than one health service. The need for transition management is not determined by age, time, place, or health care condition, but rather by patients’ and/or families’ needs for support for on- going, longitudinal individualized plans of care and follow-up plans of care within the context of health care delivery (Haas, Swan, & Haynes, 2014, p. 3).

The processes of care coordination and transi- tion management (Coleman & Boult, 2003, p. 556)

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necessitate professional assessment, patient risk identification and stratification, and identification of individual patient needs and preferences that require:

• Interprofessional collaboration and teamwork; • Evidence-based care delivery; • Patient and/or caregiver activation and empow-

erment; • Utilization of quality and safety standards; • Ability to work independently in the domain of

nursing to identify and access community re- sources that meet individual, group, or popula- tion needs.

The Conceptual Basis of the RN-CCTM Model

Other models such as the Chronic Care Model (Wagner, 1998) and a Logic Model (Haas & Swan, 2014) guided the development and organization of the RN-CCTM model. The RN-CCTM model was de- veloped as part of work by ambulatory care nurse leaders and expert panels that were sponsored by AAACN. The RN-CCTM model facilitates standardi- zation of CCTM roles in ambulatory care as well as in acute, subacute and home health care settings. It was developed based on evidence from interprofes- sional literature on CCTM.

III. The Chronic Care Model as Research Guide

Initially, the Chronic Care Model (CCM) (Wagner, 1998) was used to guide AAACN’s translational re- search project where expert panels were used to search the interprofessional literature for evidence re- garding CCTM. The CCM includes the essential ele- ments whose interactions encourage high-quality chronic disease care. “These elements include: the community; the health system; self-management support; delivery system design; decision support; and clinical information systems. Evidence-based change concepts under each element, in combina- tion, foster productive inter actions between informed patients who take an active part in their care and providers with resources and expertise” (Improving Chronic Illness Care, 2006). The CCM can be applied to a variety of health states in multiple health care settings for targeted populations. The goals are im- proved patient outcomes, optimal patient/provider interactive experience, and cost effectiveness. The CCM also informed the development of methods in the RN-CCTM model to use when communicating with patients, families, communities, and the inter- professional team and health agencies across the care continuum.

IV. The Logic Model as a Connection Tool

Secondly, the Logic Model served to illustrate the connections among dimensions and competencies il- lustrated in the RN-CCTM model and activities, inter- professional participants, and short-, medium-, and long-term outcomes (Haas et al., 2014, pp. 10-11).

AAACN initially developed and encourages the ongoing expansion of the RN-CCTM Model as the framework for RNs performing CCTM. Care coordi- nation and transition management have long been a dimension of the professional nurse role especially in ambulatory care (Haas et al., 1995). However, CCTM activities conducted by professional nurses in ambu- latory settings have often been invisible because charting or documentation in ambulatory care set- tings by nurses was not routinely required. Also, CCTM is within the scope of practice of other health care providers such as advanced practice registered nurses, physicians, pharmacists, and social workers.

Although other professionals also practice CCTM, it is the RN who has the knowledge and ex- pertise to serve as the pivotal agent of the interpro- fessional health care team by collaborating with internal team members, leading teams, educating patients and caregivers, as well as communicating with all stakeholders within the system and across the continuum of care.

V. RN-CCTM Model

The RN-CCTM model contains two major elements for its application. First, it lists the dimensions or competencies that are essential to CCTM. These in- clude (Haas et al., 2014, p. 9): 1. Support for self-management; 2. Advocacy; 3. Education and engagement of patient and fam-

ily/caregivers; 4. Cross setting communication and transition; 5. Coaching and counseling of patients, families,

and caregivers; 6. Application of the nursing process; 7. Population health management; 8. Teamwork and collaboration 9. Patient-centered care planning.

Secondly, it uses the Logic Model to link these competencies with activities, participants, and out- comes (see Figure 1).

VI. Defining Characteristics of Registered Nurses (RN) in the CCTM Role

RNs practicing in the CCTM role (adapted from AAACN, 2011; Haas et al., 2014) exhibit the following characteristics:

1. Demonstrate knowledge, skills, and attitudes requisite to the RN-CCTM dimensions.

2. Practice across the care continuum in a variety of settings, such as acute, subacute, and Patient Centered Medical Home settings such as med- ical offices, Accountable Care Organizations (ACOs), freestanding health clinics, nurse-man- aged clinics, ambulatory surgery centers, the pa- tient’s home, telehealth service environments, care coordination organizations, comprehensive health care systems, and community health care resource agencies.

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Scope and Standards of Practice for Registered Nurses in Care Coordination and Transition Management 9

Figure 1. CCTM Depicted within a Logic Model

Situation: The Care Coordination and Transition Management (CCTM) Model evolved to standardize work of ambulatory care nurses using evidence from interdisciplinary literature on care coordination and transition management. The vision is the CCTM Model would specify dimensions of CCTM and competencies needed to perform CCTM and make possible de- velopment of knowledge, skills, and attitudes needed for each competency so the registered nurse (RN) will meet needs of patients with complex chronic illnesses (and their families) being cared for in Patient-Centered Medical Homes (PCMH), as well as traditional and nontraditional outpatient settings, and acute, subacute, and home care settings, and their preparation so work as an RN in CCTM would be recognized and reimbursed by the Centers for Medicare & Medicaid Services.

Inputs/ Competencies

Outputs Activities Participation

Outcomes Short Medium Long

Support for self-management

Enhance health literacy

RN in CCTM, MD, APRN, pharmacist, social worker

Baseline compre- hensive needs assessment reflects patient values, prefer- ences, and goals

Solutions to most critical socioeco- nomic issues

Engaged, educated patient/ family, increased ability to “cope” with care interven- tions

Advocacy Negotiate and secure patient services; coach patient in self- advocacy

RN in CCTM, MD, APRN, pharmacist, social worker

Patient/family concerns and goals heard, able to access provi ders, commu- nity services, medications

Patient/family compliance with treatment plan, medications

Keep primary care appointments, appointments in community agencies

Education and engagement of patient and family

Assess readiness to learn/learning styles

RN in CCTM, MD, APRN, pharmacist, social worker, dietician, psychologist

Patient/family can “teach back” info on care interven- tions

Increased engage- ment in preventa- tive care and use of telehealth learn- ing modalities

Engaged, educated patient/ family

Cross setting communication and transition

Coordination/col- laboration between specialty and primary providers who develop and share the Patient Care Plan across settings

RN in CCTM, MD, APRN, pharmacist, social worker, dietician, psycholo gist, MD specialists, acute care, long- term care, and home care RNs

Care Plan trans- mitted between setting, changes and updates communicated

Use of electronic Patient Care Plan for handoffs

Decreased errors, duplication, decreased costs

Coaching and counseling of patients and families

Answer questions patients/families have before and after provider visit

RN in CCTM Patients/families come prepared with “Ask Me Three” questions to clinic or calls

Enhanced under- standing of health care resources in the community and need to seek consultation prior to increased severity

Decreased ED use, increased ability to “cope” with care interventions

continued on next page

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Figure 1. (continued) CCTM Depicted within a Logic Model

Inputs/ Competencies

Outputs Activities Participation

Outcomes Short Medium Long

Nursing process Assess patient for knowledge under- standing diagno- sis, needs, treatment, ex- pected outcomes of treatment

RN in CCTM Best evidence used for interven- tions/outcomes; care plan is routinely updated

Electronic process indicators show compliance with EBP plan, short- term EBP out- comes achieved

Long-term EBP disease or health outcomes achieved at 80% level

Population health management

Expert use of pop- ulation manage- ment tools (e.g., registries, analyt- ics tools) to track and monitor select population charac- teristics

RN in CCTM, MD, APRN, pharma- cist, social worker, dietician, MA, psychologist, MD specialists, acute care, long-term care and home care RNs

Maximize impact of visit or telehealth call regarding disease management, prevention, and wellness through alerts

Enhanced process improvement; enhanced immu- nization rates, participation in wellness programming

Enhanced quality of care, achieve- ment of bench- marks for prevention and wellness

Teamwork and collaboration

Inclusion of team- work in orientation and continuing ed- ucation

RN in CCTM, MD, APRN, pharma- cist, social worker, dietician, MA, psychologist, MD specialists, acute care, long-term care and home care RNs

Enhanced under- standing of inter- disciplinary roles; communication techniques

Early collaboration when issue arises, team problem solving/planning

Less “siloed” care; engaged health care team; increased appreci- ation of team member contribu- tions

Patient-centered care planning

Motivational inter- viewing; eliciting patient’s goals and priorities

RN in CCTM, MD, APRN, pharma- cist, social worker, dietician, MA, psychologist, MD specialists, acute care, long-term care and home care RNs

Individualized care plan; care planning activities transcend barriers/transitions keeping the patient at the focus

Plan of care transparent for patient/family and perceive team is listening to their preferences/goals

Enhanced patient/ family engage- ment and satisfac- tion with quality of care

Assumptions: Patients will use primary care settings; patients will access CCTM providers; patients will be engaged in care processes; providers will collaborate, work in teams, develop and use patient-centered care plans; organization will have EHRs that operate across settings; outcomes are shared by team, not discipline specific.

External Factors: Slow development of interdisciplinary team education and practice. Changes in reimbursement and penalties for “never events” are decreasing revenues, slow implementation of EMRs that are operable across settings, and slow development of model of care plan that moves between settings.

3. Apply critical and analytical reasoning and astute clinical judgment (Lavery & Hughes, 2008) in order to expedite appropriate health care and treatment given that patients and/or populations often present with complex problems and/or po- tentially life-threatening conditions.

4. Provide CCTM services throughout the lifespan for individuals, families, caregivers, groups, pop- ulations, and communities.

5. Interact with patients, health care providers, and community resource agencies during face-to- face encounters or through various types of

technological communication methods in order to assess and triage patient/population issues, provide nursing consultation, perform follow-up and surveillance of status and outcomes, and disseminate pertinent information to all members of the interprofessional CCTM team.

6. Apply appropriate evidence-based interventions that focus on patient safety and the quality of care: a) Identify and clarify the health care needs of

patients/populations; b) Coach and counsel patients/populations;

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