Care coordinator: Quarterback of the post-acute-care team

Here’s an acronym you’ll want to remember: CCTM. It stands for “Care Coordination and Transition Management.” In a world of post-acute care, population health and care continuum, chances are you’ll be serving more people – often, registered nurses — whose name is followed by CCTM.

Care coordination and transition management (CCTM) is a way for the healthcare team to involve patients and their families in organizing the patient’s care activities among several healthcare team members, healthcare services, and settings of care, says the American Academy of Ambulatory Care Nurses. CCTM helps patients navigate the maze of specialists, hospital departments, outpatient appointments, tests, procedures, medications, and follow-up appointments.

AAACN – in conjunction with Medical-Surgical Nursing Certification Board — created the CCTM™ credential in 2015. As of Nov. 15, 2017, 499 people were CCTMs. But care coordination goes back a lot further than 2015.

“Care coordination has existed in some form since the early 1900s, when nurse Lillian Wald founded the Visiting Nurse Service of New York, addressing the needs of individuals and communities while containing costs,” says Diana Harmon, MSN, MHA, RN, CCCTM, clinical instructor and continuing education planner, Emory University’s Neil Hodgson Woodruff School of Nursing. “As healthcare costs skyrocketed, care coordination evolved into case management, which was not owned by any one discipline, and which considered costs over the needs of the patient.

“We have come full circle, with nurses once again taking the appropriate role of patient advocate and team leader, who coordinates care of populations of individuals, resulting in a reduction of healthcare dollars spent,” says Harmon, who serves as chair of two AAACN committees in the Care Coordination and Transition Management program: test development and item writers.

A day in the life
An RN is particularly well-suited to coordinate care for patients who are at high risk for hospital readmission or in deteriorating health, adds Harmon. “He or she typically works as part of a team, with the physician, the pharmacist, informatics, etc. But the care coordinator is the quarterback, pulling it all together.”

The care coordinator may be found in a variety of environments – “anywhere there is an opportunity to leverage resources available through a health system, the community, the patients themselves,” says Harmon. The care coordinator may be employed by a hospital, health system, payer, outpatient clinics, etc.

“A typical day for the RN-CCTM might include the use of informatics — data extrapolated from electronic healthcare records to identify individuals in high-risk populations who would benefit from early intervention. This intervention most likely would begin with a phone call to interact with the patient and family and perform a baseline assessment. Following that, personal encounters — either home visits or office visits — allow the RN-CCTM to coach, educate, and evaluate continuing needs.

“The RN-CCTM would communicate with other members of the health team as appropriate — pharmacist, physician, etc. The RN-CCTM might also assist patients in identifying community resources for help with needs such as nutrition, mental support or transportation. Documentation and communication can be the most challenging aspect when working within an EHR that is not highly interoperable.”

It takes a high level of education to give good care to high-risk, high-cost patients, says Harmon. “Sometimes a nurse can develop those competencies through experience, but I feel very strongly that we need a structured training and certification program in place, to cultivate individuals who are going to pursue care coordination/transition management.” Some health systems already have such programs.

The AAACN Care Coordination and Transition Management course offers 13 online modules covering a variety of competencies and activities, including:

  • Education and engagement of patients and families.
  • Coaching and counseling of patients and families.
  • Patient-centered care planning.
  • Support for self-management.
  • Teamwork and collaboration.
  • Population health management.
  • Care coordination between acute care and ambulatory care.

“ Right now the domain of care coordination is fluid and rapidly evolving,” says Harmon. “In the future, I believe that the role will become more clearly defined as one that belongs to nursing, with delineated and quantifiable competencies. The development of competencies will be achieved through structured education programs for RN-CCTM nurses, available either through health systems or as continuing nursing education activities, with the ultimate confirmation of expertise demonstrated through certification in CCTM.”

Care coordination by any title

Nurses who practice in a care coordination/transition management role may carry any number of titles, including

  • Care coordinator.
  • Transitions manager.
  • Care manager.
  • Nurse navigator.
  • Transitional care manager.
  • Health coach.
  • Discharge planner.
  • Patient care coordinator.
  • Patient care facilitator.

Source: Medical-Surgical Nursing Certification Board

Care coordination or case management?

The Medical-Surgical Nursing Certification Board makes the following distinction between care coordination and case management:

“CCTM, in its broadest sense, deals with populations of patients over time, especially those with chronic illnesses/diseases such as diabetes, heart disease, asthma, etc. Case management, on the other hand, deals more with the utilization of resources. For example, helping the patient with insurance and payment issues and health resources needed when they return home (e.g., home health nurse, supplies).”

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