Nurse Care Coordination model that features six nurse care coordination activities regularly performed by staff nurses in hospital settings as part of their daily activities—mobilizing, exchanging, checking, organizing, assisting, and backfilling (Lamb et al., 2008). Box 2-5 describes a program in the community setting called Living Independently for Life (LIFE), a PACE program in Pennsylvania that is led by nurse practitioners and provides interprofessional health services to low-income, frail, chronically ill older adults who are eligible for nursing home care (LIFE, 2010).
In acute care settings, care coordination is showing particular promise in efforts to reduce rehospitalizations. All 15 demonstration program sites under the Medicare Coordinated Care Demonstration program, for example, adopted interventions that relied on nurses as care coordinators (Peikes et al., 2009). Box 2-6 provides an in-depth look at the Transitional Care Model, developed by nursing researcher Mary Naylor. This model was designed to facilitate patients’ transitions within and across settings and to break the cycle of acute flare-ups of chronic illness. The protocol goes beyond usual case management and home care by employing an APRN who is proficient in comprehensive in-hospital assessment, evaluation of medications, coordination of complex care, and in-home follow-up. By collaborating with the patient, family caregivers, specialists, primary care providers, and others, this nurse works to improve the management of multiple complex chronic conditions and thus reduce readmissions.
Many of the roles health professionals are being called upon to fill in the evolving U.S. health care system are not technically new. Nurses, physicians, and pharmacists, for example, have educated patients, helped coordinate care, and collaborated with other clinicians for decades. What is new is the extent and the centrality of these roles. Previous IOM studies have found that systemwide changes are necessary to meet higher standards for quality care, the growing requirements of an aging population, and the need to deliver more care in the community setting. Crossing the Quality Chasm introduced the idea of the advisability of expanding the scope of practice for many health workers (IOM, 2001). Retooling for an Aging America advised that meeting the needs of the growing geriatric population would require expanding the roles of health professionals “beyond the traditional scope of practice” (IOM, 2008).
In light of these considerations, the committee concludes that nurses, in concert with other health professionals, need to adopt reconceptualized roles as care coordinators, health coaches, and system innovators. This chapter has already provided examples of nurses working as care coordinators; the following subsections elaborate on what the committee means by health coaches and system innovators. Filling these roles, whether in entry-level nursing or advanced practice, will require that nurses receive greater education and preparation in