Category Archives: Coordinated care

Jan 9 2014

Guide to Nursing’s Role in Care Coordination

A new guide, Care Coordination: The Game Changer—How Nursing Is Revolutionizing Quality Care, explores how care coordination is positioned in the context of health reform. It was published by the American Nurses Association (ANA).

Care coordination has long been an integral part of nursing practice, the ANA said in a news release, with registered nurses leading the way in designing and delivering successful team-based care coordination programs that improve patient care and reduce costs. In the book, editor Gerri Lamb, PhD, RN, FAAN, and 23 leaders in care coordination explore topics including:

  • A historical perspective on nursing and quality care;
  • The role of care coordination in quality and safety;
  • Models and tools for improving quality and safety;
  • The role of nurse leaders in advancing care coordination;
  • The care coordinator’s role in reducing avoidable hospital stays;
  • Partnering with patients and families for better outcomes; and
  • Community-based care transitions.

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Feb 7 2013

Tootsie’s Story, Continued: A Family Wonders Whether Nurse-Led Care Coordination Might Have Prolonged a Life

Jennifer Bellot, PhD, RN, MHSA, is an assistant professor at Thomas Jefferson University and a Robert Wood Johnson Foundation Nurse Faculty Scholar. Yesterday, she blogged about the death of her beloved grandmother, Tootsie, due to complications from medical error that began with an overdose of Synthroid.  This is Part Two of Bellot’s blog post.


In 2010, the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM) joined resources and released The Future of Nursing: Leading Change, Advancing Health. This landmark report included many recommendations, and a full-scale Campaign for Action is in place that will transform nursing for years to come. Among the many themes advocated in this report is the tenet that nurses should be the very core of reinventing the American health care system. The report encourages the health care system to lean, and lean heavily, upon the skill set and resources of nurses to facilitate access to higher quality care at a lower cost.

At present, we have a health care system that is technology and intervention heavy when we know our population demographics are rapidly changing and technological intervention is not always the right answer. We have a growing need for a system that instead focuses on addressing chronic disease management, prevention and wellness care. Nurses are well positioned to support a system with these foci, managing care of the older adult in the community before inpatient care becomes necessary. Specifically in the outpatient setting, nurse coordinated care that is, by definition, proactive, holistic and comprehensive will help shift the focus of care from acute and episodic to chronic and preventive.

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Feb 6 2013

Tootsie’s Story: Medical Error Takes a Life

Jennifer Bellot, PhD, RN, MHSA, is an assistant professor at Thomas Jefferson University and a Robert Wood Johnson Foundation Nurse Faculty Scholar. This is Part One of a two-part blog about the death of her beloved grandmother.


Just over a year ago, our family lost our beloved matriarch and my grandmother, “Tootsie,” to complications from a medical error.  It’s hard to believe that it’s been over a year now and each day, we feel her loss—or presence—in different ways.  I write about this remarkable woman in this month’s issue of Professional Case Management.

Tootsie was an amazing example of strength, generosity, and perhaps most characteristically, of someone who spent her life caring for others.  She bore eight children in nine years, raised them almost single-handedly after her husband died prematurely, and managed a 160-acre farm—all without a high school degree. Tootsie and I had an especially close relationship, blossoming one summer when I lived with her as a preschooler while my mother pursued her graduate degree.

As I grew older, I would become involved in Tootsie’s medical management. She would regularly send me copies of her lab reports and medical records. Medical talk became our currency of love. We chatted about her latest cardiology consultation like others might chat about celebrity gossip. Following and safeguarding her health was how we shared our love best.

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Nov 30 2012

What Should Health Professionals Know About Handoffs?

Michael D. Cohen, PhD, is the recipient of a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research, and the William D. Hamilton Professor of Complex Systems, Information and Public Policy at the University of Michigan School of Information.


Handoffs are a critical link in maintaining continuity of care during a hospital stay. Whenever there is a shift change, or when a patient moves between departments (such as from an Emergency Room to an inpatient unit), there should be communication between the personnel who have been caring for the patient, and those who are to assume responsibility. These handoffs have to be done effectively. Root cause analyses of sentinel events find communication breakdowns to be major contributing factors nearly two-thirds of the time, and a large fraction of those problems occur during handoffs.

It seems logical that nurses and doctors should receive some training in how to conduct these vital conversations, but in interviews during my research on handoffs, it has been rare to find a practitioner who learned anything in nursing or medical school about how to hand off effectively.

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Feb 10 2012

Going It Together: Physician Visits as a Family Affair

By Jennifer L. Wolff, PhD, and Robert Wood Johnson Foundation Physician Faculty Scholar Cynthia M. Boyd, MD, MPH

file Jennifer Wolff

It is widely recognized that family members and trusted friends make an enormous difference by assisting disabled older adults with daily household and personal activities. There is less awareness, however, that families and trusted friends also often help older adults navigate our complex and fragmented health care system to get the best care possible—by scheduling and arranging transportation to appointments, engaging in medical decision-making, or overseeing adherence to health care treatments. As we learn more about how older adults navigate the health system, it is becoming clear that they often do so with the support and active engagement of a “family companion” —and that this role is enduring.

file Cynthia Boyd

In a study we published in the January issue of the Journal of the American Geriatrics Society (JAGS), we found that nearly one-third of adults over age 65 were accompanied by what we called a “family companion” during routine physician visits. These companions were almost always family members (93.3 percent), and they typically accompanied their loved one to physician visits on a regular basis—70.3 percent were identified as “always” present.

We were surprised by the persistence and consistency of family companion involvement. Three quarters (74.5 percent) of older adults continued to be accompanied by a companion at one year follow-up, nearly always the same family companion (87.1 percent).

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Feb 7 2012

Insurer's New Program Will Raise Reimbursements for Primary Care Providers

In late January, the nation’s second-largest health insurer announced a new initiative designed to improve care and reduce costs by raising reimbursements for primary care. WellPoint will provide additional revenue to primary care providers for “non-visit” services that it does not currently reimburse, such as preparing care plans for patients with multiple and complex conditions. The new program is designed to build and expand on WellPoint’s existing medical home program.

“Primary care physicians who are committed to expanding access, to coordinating care for their patients and being accountable for the quality of care and the health outcomes of those patients, will get paid more than they do today, and we’re committed to helping them achieve these quality and cost goals,” Dr. Harlan Levine, WellPoint executive vice president, Comprehensive Health Solutions, said in a statement. “Primary care is the foundation of medicine, and it can and should be the foundation of our members’ health.”

WellPoint predicts the program will reduce overall medical costs by as much as 20 percent by 2015. The program will launch in select markets later this year.

Read more about the shortage of primary care providers in the United States here and here.

Oct 4 2011

New Federal Initiative Aims to Improve Care Coordination

The U.S. Department of Health and Human Services (HHS) last week announced the launch of the Comprehensive Primary Care Initiative, to improve the quality of care for Medicare and other patients. The voluntary program, which will begin as a demonstrative model in five to seven markets, encourages primary care doctors and nurses to work with specialists and other health care providers to better coordinate patients’ care.

Primary care providers will receive support and resources to help develop personalized care plans for patients with complex health care needs, offer 24-hour access to care and health information, deliver preventive care, and engage patients and their families in their own care. Practices that do that so will receive an additional monthly fee from Medicare in markets where private insurers agree to do the same. The increased focus on prevention and care coordination is expected to results in savings that will later be shared with primary care practices that participate.

“This collaborative approach has the potential to strengthen the primary care system for all Americans and reduce health care costs by using resources more wisely and preventing disease before it happens,” HHS said in a release.

"The American College of Physicians (ACP) believes that the Comprehensive Primary Care Initiative offers enormous potential to promote the kind of personalized and coordinated care that patients seek and that physicians want to deliver," said Steven Weinberger, MD, FACP, executive vice president and CEO of ACP. "It will provide primary care physicians with the support needed to work hand-in-hand with patients toward a shared goal of ensuring high quality care while making the most efficient use of health care resources… Internal medicine physicians know from their personal experiences that when care is coordinated and centered on patients’ needs and expectations, through a primary care practice that uses proven 'best practices' and is accountable for the results, outcomes are better and costs are lower."

Learn more about the Comprehensive Primary Care Initiative.

Jan 7 2011

Clinical Scholars at Yale University Found Nonprofit to Enhance Access to Specialty Care

In 2008, six RWJF Clinical Scholars at Yale University set out to improve health care in New Haven, Connecticut. They envisioned a coordinated system of physicians, hospitals and community organizations working together to provide donated specialty health care for people who have the most trouble getting it: the poor and uninsured.

This September, their vision became a reality with the opening of Project Access–New Haven. The project provides eligible applicants with patient navigators, who help their assigned patients connect to specialty health care in their community. The project has so far helped 46 patients access care.

But the project does more than just connect patients to health services. Project Access-New Haven organizers also aim to narrow health disparities, collect and report data on care utilization and associated costs, and create a blueprint for other specialty care health systems.

“For too long, academic centers have ignored the needs of the populations around them,” said Harlan Krumholz, M.D., S.M., director of the Clinical Scholars program at Yale University. “With the Foundation’s support, we are seeking to train physicians and leave a legacy of contribution to the community through scholarship and service.”

Read the story.