...over 40 different definitions have been associated with the term [care coordination]. The concept of care coordination is often touted as the preferred way to streamline care for complex patients (Boult, et al., 2011; Coburn, Marcantonio, Lazarsky, Keller, & David, 2012; Counsell, Callahan, Buttar, Clark, & Frank, 2006; Dorr et al., 2007). The term “care coordination” means different things to different patients, providers and policy makers; over 40 different definitions have been associated with the term (McDonald et al., 2014). The concept is even more popular with the mention of care coordination in the Affordable Care Act of 2010 (Lind, 2013); new payment models aimed at decreasing the per capita costs of care for the Medicare program (Reinhard, 2011); and development of the Institute for Healthcare Improvement (IHI) Triple Aim Initiative (Berwick, Nolan & Whittington, 2008; IHI 2015).

The purpose of this article is to define care coordination, briefly describe trends for older adults and care coordination, and explore roles for registered nurses. We describe elder-appropriate models of care coordination useful for older adults with multimorbidity. A brief exemplar provides an example of evidence-based care coordination services provided by a nursing and social work team, a model supported by recent literature. As a result of this discussion, readers will become informed about possibilities for the future of care delivery and the future of professional nursing practice.

Defining Care Coordination

A search of academic journals using the term “care coordination” in the Cumulative Index of Nursing and Allied Health Literature (CINAHL) database yielded 1830 results....care coordination is a current term related to many different aspects of healthcare delivery and is associated with a variety of concepts. Major subject headings associated with care coordination included: primary healthcare (180 citations); case management (179); continuity of patient care (177); quality of healthcare (119); patient-centered care (112); and health services accessibility (88). The diversity of major subject headings indicates that care coordination is a current term related to many different aspects of healthcare delivery and is associated with a variety of concepts. Care coordination is a strategy used by different providers and with different age groups (Beland & Hollander, 2011; Berry, Rock, Houskamp, Brueggmenn, & Tucker, 2013; Coleman et al, 2004). For example, its multiple applications may vary by any number of factors, such as age of the population being served by care coordination; needs based on the patient’s condition (e.g., managing disabling conditions or chronic diseases); type of provider organization offering care coordination services; and payer sources (McDonald et al., 2007). A model of care coordination for an older adult with multimorbidity (i.e., multiple diseases) will likely look very different than a model for a pediatric population needing services to manage physical disabilities.

Terms or phrases to describe care coordination may include: case management, care management, continuity of care, integrated care, or coordinated care. For the purpose of this article, the Agency for Healthcare Research and Quality (AHRQ) definition for care coordination will be used. According to AHRQ:

A model of care coordination for an older adult with multimorbidity (i.e., multiple diseases) will likely look very different than a model for a pediatric population needing services to manage physical disabilities. Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services. Organizing care involves the marshalling 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 difference aspects of care (McDonald et al., 2014, p. 6).

For the purpose of this paper, “models of care coordination” are structures and processes associated with intentional organizing or coordinating of patient care activities.

Older adults account for 13% of the population. In 2012, the American population of adults over the age of 65 numbered 43.1 million, an increase of 21% in 10 years since 2002 (Federal Interagency Forum on Aging-Related Statistics, 2012). With the aging of “Baby Boomers” (those born between 1946 and 1964, who started turning 65 in 2011), the acceleration of older adults will continue to rise. By 2040, 20% of the population will be comprised of persons 65 and older; and by 2050 an estimated 88.5 million people will be over 65, more than doubling the number of those 65 and older in 2008 (38 million) (Anderson, 2010).

Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services. The most significant challenge associated with the growing numbers of persons enrolled in the Medicare program is the increase in healthcare spending tied to older adults with multimorbidity, or those with two or more chronic conditions (McDonald et al., 2007). As Americans are living longer than ever before, many are living with chronic conditions such as hypertension, other diseases of the heart, respiratory disease, arthritis, and diabetes (Centers for Medicare & Medicaid [CMS], 2012). Over 90% of older adults have at least one chronic condition (McDonald et al, 2007). Over 68% of Medicare beneficiaries have two or more chronic conditions, and over 36% had four or more chronic conditions (Lochner & Cox, 2012). Persons with chronic health conditions account for 84% of all healthcare spending in the United States and are the most expensive users of healthcare services (Anderson, 2010). Furthermore, persons with multiple chronic conditions cost up to seven times as much as those with only one chronic condition (AHRQ, 2006).

These emerging population trends support the importance of exploring new models of care that meet the Institute for Healthcare Improvement (IHI) Triple Aim Initiative dimensions of population health, patient experience, and per capita cost (IHI, 2015). Per this initiative, providers are tasked to reduce per capita costs associated with care while improving population health and the patient experience of care (Berwick, Nolan & Whittington, 2008).

Models of care coordination developed in the past decade frequently address increasing healthcare needs of the population over age 65 who receive Medicare benefits (Coburn et al, 2012; Counsell et al., 2006; Dorr et al., 2006). For example, the federal government has created demonstration projects to manage the high costs of Medicare associated with the complex needs of a large population of older adults (Brown, Peikes, Chen & Shore, 2008; Brown, Peikes, Peterson, Schore, & Razafindrakoto, 2012, Bott, Kapp, Johnson & Magno, 2009; Coburn et al., 2012; Tinetti, Fried, & Boyd, 2012). Professional nurses need an understanding of the demand associated with an increasing number of older adults with complex needs. Knowledge about current and future strategies for creating affordable Medicare programs, will support a preferred future (i.e., the best possible outcome for the least cost) for older adults with multimorbidity.

To address current and future costs associated with caring for older adults with multimorbidity, the Affordable Care Act (ACA) of 2010 (AARP, 2013) contained initiatives that targeted reducing costs of Medicare through improving care coordination and transitional care. One ACA initiative included $300 million in funding for Medicare Community-based Care Transitions Program (CCTP) and another was a $500 million initiative to support programs that reduce avoidable 30-day hospital readmissions and preventable hospital-acquired conditions (AARP, 2013).

Registered nurses are, and will be, key providers of care coordination... Other ACA programs have the potential to impact care management of older people with complex needs. For example, the Medicare Independence at Home Demonstration is designed to test whether house calls by primary care providers (PCP) improve quality of care and patient outcomes. Another ACA program is the patient-centered medical home initiative where a team provides care coordination that incorporates both medical and non-medical care for complex patients (AARP, 2013). Lastly, the ACA stimulated a federal program to test models of chronic care coordination through the CMS Innovation Center. Programs to be tested relative to care coordination through the CMS Innovation Center include Accountable Care Organizations (ACOs) and bundled payment programs for improved care of both acute and post-acute episodes of care (AARP, 2013). To understand this future direction in nursing, registered nurses (RN) must learn and appreciate how these policy-generated programs will inform future models of care delivery. Registered nurses are, and will be, key providers of care coordination in these programs and future models of care that address the high costs associated with providing care to Medicare beneficiaries.

Registered Nurse Roles in Care Coordination

Models of care coordination in the United States and around the world use RNs in care coordinator roles (de Stampa et al., 2014; Beland & Hollander, 2011; Boult et al., 2011; Schraeder et al., 2008 & Bernabei et al., 1998). This section will identify the roles of RNs in care coordination, outcomes associated with measuring their care coordination, and how to work collaboratively with a team for improving the quality of care for older adults with multimorbidity.

Defining Roles in Care Coordination

Terminology. Just as there are many terms used for care coordination, there are also a variety of terms used to identify the care coordinator. Just as there are many terms used for care coordination, there are also a variety of terms used to identify the care coordinator. Studies that have examined roles of RNs as care coordinators have used the following names: care coordination nurse (Berry et al., 2013); patient care facilitator (Skillings & MacLeod, 2009); transition coach (Coleman et al., 2004); chronic condition care coordinator (Ehrlich, Kendall & Muenchberger, 2012); and patient care coordinator (Brown et al, 2005). Some organizations even use care coordinator to refer to the person who is not licensed and serves in an administrative role to set up appointments and provide other helpful clerical duties to arrange an individual’s care.

Research and Use of RNs. In addition to the variety of role definitions, there are also a variety of providers that use RNs as care coordinators. Research has been done on RNs as care coordinators in settings such as primary care (Ehrlich et al., 2012); hospitals (Skillings & MacLeon, 2009; Brown et al., 2005); an integrated delivery system (Dorr et al., 2006); senior housing (Rantz et al., 2011); and for clients insured through a large payer (Hong, Siegle & Ferris, 2014).

More and more patient-centered medical homes use RNs rather than medical assistants for their care coordination efforts. Studies have demonstrated that primary care physicians appreciate the ability to turn over the coordination of care to an RN (Boyd et al., 2007; Marsteller et al., 2010). A Robert Wood Johnson Foundation poll of physicians found that physicians are discouraged by the amount of social and non-medical care activities that they are unable to address (RWJF, 2011). RNs may be more cost effective than unlicensed providers because they do not require the same level of targeted education, supervision and support as an unlicensed assistant for delivering high quality care. Physicians may have more confidence and trust in a licensed caregiver rather than a medical assistant.

Competence in communication, coordination, relationship development and providing support were common roles of the RN care coordinator in a variety of studies. Competence in communication, coordination, relationship development and providing support were common roles of the RN care coordinator in a variety of studies. For example, studies have identified the importance of the RN role to help patients comply with the medical plan of care and have described how the RN care coordinator reinforced components such as management of medication and symptoms indicative of a worsening condition (Beland & Hollander, 2011; Bernabei et al., 1998; Berry et al., 2013; Boult et al., 2011; de Stampa et al., 2014; Ehrlich et al., 2012; Schraeder et al., 2008). This role highlights the importance of not just coordinating care between providers, but also reinforcing medical recommendations to the patient from a specific physician. Berry et al. (2013) stated that one of the most important roles of RN care coordinators is to support the patient-physician relationship so patients are more likely to adhere to the prescribed medication regimen, and thus help physicians achieve greater efficiencies in their medical care.

Review of the literature has demonstrated that face-to-face visits have historically been a part of the care coordinator role, in addition to email and telephone coordination with clients (Berry et al., 2013; Beland & Hollander, 2011; Bernabei et al., 1998; Boult et al., 2011; de Stampa et al., 2014; Ehrlich et al., 2012; Schraeder et al., 2008; Skillings & MacLeod, 2009). The face-to-face presence of the care coordinator when providing services fosters relationships between care coordinators and patients and leads to improved understanding of shared goals, strengths, fears, and nonmedical challenges (Ehrlich et al., 2012). Research has also suggested that face-to-face interactions improve overall outcomes associated with the model of care coordination (Brown et al., 2012).

Studies have demonstrated common aspects of the RN care coordinator role, including collaboration with physicians and other members of the care team; patient education; medication management; and managing patient transitions among care settings (Brown et al., 2012; Ehrlich et al., 2012; Skillings & MacLeod, 2009). In summary, multiple research studies have demonstrated that the RN care coordinator position requires mastery of quality and safety measures; understanding about community resources; knowledge of working with chronically ill elderly; ability to collaborate with consumers, other professionals and agencies; excellent communication and negotiation skills; and ability to interpret protocols and apply to specific client conditions. Table 1 lists essential functions of the RN care coordinator.

Table 1. Essential Functions of Care Coordinator

(Social Work Leadership Institute, 2008; Transitional Care Model, 2014).

Measuring Outcomes in Care Coordination by RNs

Without one clear and consistent role description of the RN care coordinator, measurement of the impact of the RN care coordinator on patient outcomes has been difficult, but there is some progress to report. In an integrative review, Joo (2014) identified that nurse-led, community-based, case management led to overall reduction in hospitalization and readmissions; and positive client-focused outcomes (e.g., improvements in quality of life, greater symptom control, better patient satisfaction). According to the American Nurses Association (ANA), the value of RNs in care coordination has been demonstrated in numerous studies and healthcare reform initiatives (ANA, 2012). The ANA (2012) has concluded that RNs provided the following benefits to patients and providers of care coordination services:

• Reduced emergency department visits
• Decreased medication costs
• Reduced inpatient charges
• Reduced overall savings per patient
• Decreased mortality
• Reduced readmissions
• Lowered total annual Medicare costs for beneficiaries
• Increased patient confidence in self-management of care
• Improved patient satisfaction with care

The ANA summary from multiple research studies provides ideas for outcome measures for future nursing research of new models of care coordination. These outcomes can be captured and tracked in electronic health records associated with patient care, and may be especially useful to measure outcomes of the complex care of older adults with multimorbidity.

The complexity inherent in our healthcare delivery system makes evaluating the cost effectiveness of care coordination challenging. Developing standards for care coordination and defining successful outcomes will continue to be challenging. Answers to the challenging questions are needed for policy-makers who arrange payment for state Medicaid and federal Medicare; as well as for healthcare system leaders including insurance executives and hospital leaders. The complexity inherent in our healthcare delivery system makes evaluating the cost effectiveness of care coordination challenging. Reducing costs, while also maintaining or improving a positive patient experience and positive client outcomes, offer the greatest likelihood of program sustainability (Browdie, 2013).

Attributes Required for RN Care Coordinators

Clinical experience. Employers want experienced nurses to practice as the care coordinator. Clinical experience as a case manager may be required and orientation to the role of care coordinator may include review of web-based resources. Berry et al. (2013) noted that at Gundersen Medical Center, the complexity of patient needs drove hiring decisions toward mature nurses who had astute critical thinking skills, a sense of humor, a nonjudgmental temperament, and an affinity for teamwork.

Employers want experienced nurses to practice as the care coordinator. Education. Organizations may wish to hire only RNs prepared with a bachelor’s or higher degree in nursing. Broader educational preparation prepares the RN to work independently and problem solve with greater impact. Most models described in peer reviewed literature have RNs as care coordinators (Beland & Hollander, 2011; Boult et al., 2011; Boyd et al., 2007; de Stampa et al., 2014; Schraeder et al., 2008 & Bernabei et al., 1998).

Communication skills. When various professionals participate in care of the client with multimorbidity, the ambiguity of roles may lead to disintegration of the care coordination model. Effective communication with patients as well as with members of the care team was identified as essential across many studies associated with the RN care coordinator (Berry, et al, 2013; Ehrlich et al., 2012; Skillings & MacLeod, 2009). Communication skills were important to negotiate the care coordinator role with other members of the team and to take on leadership skills to manage people and new situations (Ehrlich et al., 2012).

Teambuilding skills. Care coordination is a team sport and other providers are needed to achieve high quality, cost effective services. ...ambiguity of roles may lead to disintegration of the care coordination model. Again, this may be especially true in the complex cases of older adults with multimorbidity. Other members of the team each have a role to play in meeting an individual’s needs across the continuum of care. For example, team members may include a pharmacist to help with medication management; a physical therapist to help improve functional status; a social worker to address the psychosocial needs of an older adult; and a physician to manage the medical diagnosis and medical plan of care.

Social workers have been designated as an essential partner for the advanced practice nurse in the Geriatric Resources for Assessment and Care of Elders (GRACE) model of care coordination (Counsell et al., 2006). A social worker may be most appropriate for managing patients with predominantly psychosocial issues. Specific psychosocial needs of an older adult, such as arranging transportation; extended care; mental health services; and other services to support non-medical health-related needs, often fall under the purview of social workers. Table 2 offers a brief exemplar that describes a recent care coordination model implemented using social workers and RN care coordinators within a large primary care organization.

Unlicensed assistants (e.g., medical assistant or community health worker) also contribute to care coordination. The assistant may be the one who helps a patient to schedule appointments or manage electronic records; calls with a reminder about appointments and goals; or may serve as the interpreter and coach for someone within a specific ethnic group.

Table 2. Brief Exemplar: A Practice-Based Model of Care Coordination

The versatility of the RN role means that he or she is often the professional who bridges gaps between the complex patient’s mental and physical needs. The versatility of the RN role means that he or she is often the professional who bridges gaps between the complex patient’s mental and physical needs. As described above, each team member brings unique professional expertise to the care of individual patient needs. These specific needs are the deciding factors that inform the decision about who participates on the care coordination team.

Researchers have concluded that RN nursing judgement was a positive factor to decide how best to use resources associated with models of care coordination and whether a patient would benefit from care coordination (Ehrlich et al., 2012). The next section will describe some models of care coordination particularly relevant to caring for elders.

Elder-Appropriate Models of Care Coordination

Models of care coordination are programs that provide a consistent structure for coordinating and organizing care for older adults. Models of care coordination are programs that provide a consistent structure for coordinating and organizing care for older adults. The program will help the older adult have a reliable resource person and interface within the healthcare system to assure that all services are accessible and there are no redundancies in diagnostic tests. The program provides a hub for all communication about the person’s health (e.g., diagnostic test results, medication regimen, medical conditions, plan of care).

In 2002, prior to the ACA enactment, the CMS announced the selection of 15 demonstration programs for participation in a Medicare Care Coordination Demonstration (MCCD). These programs served as the first random assignment, multisite studies of care coordination (Brown, Peikes, Chen & Shore, 2008). Each program designed their care coordination program with the goal of reducing hospitalizations of chronically ill individuals.

Reducing costs of care associated with older adults is often measured by decreasing the number of hospitalizations, because hospitalizations are the most expensive part of the care trajectory. Over the first four years of the demonstration, only two of the 15 programs met the goal of reducing hospitalizations. After an additional two years of study, and through use of an increased sample size of Medicare participants in the remaining 11 pilots, two new programs were identified, for a total of four programs that significantly reduced number of hospitalizations. These four programs all had RNs as care coordinators (Brown et al., 2012). Table 3 lists other common components of the successful programs.

Table 3. Successful Components of Models of Care Coordination

(Brown et al., 2012)

...a focus only to reduce per capita costs of care may not be adequate for sustainability of models of care coordination. Models of care coordination are often developed with the single focus of reducing the high costs associated with care for the older adult with multimorbidity. Yet, a focus only to reduce per capita costs of care may not be adequate for sustainability of models of care coordination. Research has demonstrated that a solitary focus on cost reduction in primary care also reduces staff member satisfaction and leads to poorer patient satisfaction with primary care (Rodriguez, von Glahn, Elliott, Rogers, & Safran, 2001). The Triple Aim framework for healthcare delivery suggests that successful programs for redesigning healthcare delivery will also incorporate goals to improve the health of populations and the patient experience, and not just reduce per capita cost of care. According to the IHI, all three aims are needed for redesigning models of care for the future. In theory, models of care coordination that incorporate all three dimensions of the Triple Aim have a greater likelihood of long term success (Berwick, Nolan & Whittington, 2012).

Models of care coordination can be housed within a variety of different provider groups. Many models are hosted or integrated by large primary care practices or groups of primary care providers to gain an economy of scale sufficient to support hiring an RN care coordinator. Other models may be hosted by a community group, a university, or an integrated care organization that includes a corporate structure for integrating primary and acute care. Examples of four elder-appropriate models of care coordination are provided in Table 4. Measuring success in these programs remains difficult. Yet each of these programs has been in place for at least five years and has a scientific background suggesting that the model does make a positive difference for older adults with multimorbidity.

Table 4. Overview of Four Elder-Appropriate Models of Care Coordination

Conclusion

In summary, America’s healthcare system is on a pathway to a preferred future for care delivery for older adults with multimorbidity. Registered nurses and their care coordination teams will streamline care processes to reduce the cost burden associated with meeting the complex health needs of these older adults. As the population of older adults with multimorbidity continues to increase, the demand for registered nurse-led care coordination teams will also increase. Through a greater understanding of potential roles and new models of care coordination, nursing in the future will continue to thrive and provide high quality care for all, and especially older adults who need their expert care.

Authors

Jean Scholz, MS, RN, NEA-BC
Email:scholzja@mail.uc.edu

Jean Scholz is a results-oriented nurse leader who approaches everything with innovation; whether it is working for associations to grow membership and increase influence or developing relationships to secure sustainability for a non-profit. Known for her ability to collaborate, Jean has specific expertise in training future nurse leaders, organizing successful change projects, forecasting future care delivery models, writing and public speaking. Over the last 25 years, Jean has served in leadership roles in clinical operations and health policy including in professional and trade associations; and was President and CEO of the Colorado Center for Nursing Excellence. She has also consulted with organizations dedicated to transforming nursing and healthcare delivery. She was one of a select group of nurse leaders chosen for the prestigious Robert Wood Johnson Foundation’s Nurse Executive Leadership program in 2003. Jean is currently a student in the University of Cincinnati’s PhD program for Nursing Research. Her dissertation research is on the older adult with multimorbidity and their experience with care coordination.

Judith Minaudo, RN
Email: jminaudo@copcp.com

Ms. Minaudo graduated from Columbus State Community College with an ADN degree. Her nursing career spans several decades of acute care hospital nursing and practice management. She currently serve as the PCMH coordinator and Quality Improvement Manager for Central Ohio Primary Care Physicians in Columbus, Ohio. From 2010-2014, Ms. Minaudo successfully submitted 44 primary care practices for PCMH Level 3 certification. Currently, she manages staff from both the Quality and Population Health Departments. COPC’s Quality staff (3 RNs, 1 LPN and 1 MS) work in the corporate offices managing patient populations thru payer specific reports, whereas the Care Coordinators (5 RNs and 5 MSWs) work one on one with the high risk patient population in 34 adult primary care offices and in the patient homes.