Care coordination: Identifying and connecting the most appropriate care to the patients.

Although nurses are increasingly expected to fulfill the role of care coordinator, the knowledge and skills required to be an effective care coordinator are not well understood. The purpose of this study was to describe the knowledge and skills required in care coordination practice using an interpretive phenomenological approach. Fifteen care coordinators from 10 programs were interviewed over a 6-month period. Semi-structured face-to-face interviews were audio recorded, transcribed, and analyzed using interpretive phenomenology. The central theme of care coordination practice was bridging the patient and the healthcare systems. To bridge, care coordinators needed to have knowledge of the patient and healthcare system as well as the skills to identify and negotiate treatments appropriate for the patient. The most salient finding and new to this literature was that care coordinators who used their medical knowledge about available treatment options to discern and negotiate for the most appropriate care to the patient made differences in patient outcomes. Nurses with medical and healthcare system knowledge, combined with the skills to navigate and negotiate with others in an increasingly complex healthcare system, are well situated to be care coordinators and generate optimal outcomes. Further investigations of critical care coordinator competencies are needed to support nurses currently enacting the role of care coordinator and to prepare future nurses to fulfill the role.

Centering the concept of transitional care: a teaching-learning innovation.

Coordination of care, including the provision of safe and effective transitions, is a core professional standard for nurses. However, as currently designed, prelicensure nursing education prepares nurses to function in discrete settings rather than across settings. A teaching-learning innovation focusing on transitional care was implemented as an educational pilot project with 20 senior-level baccalaureate students in their leadership course. Students in the educational pilot immersed in the subject of transitional care via concept-based learning activities and performance improvement projects. During the course, students were assigned to designated clinical sites representative of a continuum of care. An integrated clinical postconference offered students the opportunity to discover the role of the nurse in transitional care from a systems perspective and facilitated a deeper understanding of the subject that extended beyond the walls of students' discrete clinical sites.