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The long term care industry is an intricate network of healthcare providers tasked with accommodating residents on each stage of their care plan, from inpatient to outpatient to community resources. Such high-level coordination requires strong and consistent communication. That is why the Agency for Healthcare Research and Quality (AHRQ) stipulates that care coordination should prioritize resident care by sharing all relevant information among the concerned healthcare providers.

Coordination of care in nursing helps nurses and other team members deliver high-quality care administered by the right people to achieve optimum care outcomes. This goal is achieved by sharing resident information with the relevant parties via an effective care plan software, which guides medical professionals to deliver safe, appropriate, and effective care practices. 

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On paper, care coordination seems simple: physicians and specialists collaborate to provide the best possible treatment for residents. However, in reality, coordination of care in nursing is often plagued with obstacles like miscommunication, parrot charting, missed assignments, lack of accessibility to specialists, and lack of other resources or funding. 

These challenges to coordination of care in nursing are why it is important to have an efficient and advanced long term care software system. It also helps to have strong and competent leaders in place so that a higher standard of coordination is enforced. This was articulated by Barbara Klick—CEO of the Sholom Community Alliance in Minneapolis, Minnesota—who recently joined the LTC Heroes podcast to discuss how she uses her nursing skills, experience, and business acumen to focus on quality and coordinated care for her residents. You can listen to the interview below: 

Klick stated that there is no contradiction between emphasizing quality and remaining profitable. “If you keep quality at the center of everything you do while also keeping the lights on and having some money left over for investment, you have the perfect foundation for a culture that reignites staff’s passion, vision, and inspiration,” she said. Rather, by way of solid leadership and embracing the facility’s culture, she and other leaders can send a unified message to teams to constantly strive to move forward, overcome hardships and celebrate their victories. 

The Types of  Nursing Care Coordination

For long term care facilities, there is always a delicate balancing act to provide optimum care. This begins with the nursing care coordination in the facility. But successful nursing care coordination can only improve a facility’s efficiency and care outcomes when multiple factors are coordinated and synchronized. Leaders like Klick focus on making sure these pieces, like the right equipment, appointment, food, and medication, are in sync with each other. After ensuring that they are, she can focus on the transitions of care “from primary care to the emergency department, to home or back to transitional care.”

As mentioned earlier, successful nursing care coordination requires strong communication between the healthcare providers so residents and patients can transition between the services harmoniously. Several elements need addressing to ensure that adequate care coordination is synchronized between the multiple healthcare providers and specialists. These elements include

  • Accessibility to different healthcare services and providers
  • Open communication between healthcare providers to ensure smooth transitions
  • Targeted focus on the individual needs of a resident
  • Clear and easy to understand the information given to residents

Failure to synchronize can result in medical errors, poor care standards, and high mortality rates. “Care coordination really is the glue that keeps everything together,” said Klick. “It really can be the lifeline for the patient and the resident.”

As we know, the healthcare industry covers a broad scope of care, services, and patients. With so many factors involved, it is not surprising there are numerous types of coordination of care in nursing catering to the different needs of patients and residents. The three most prominent types of coordination of care in nursing are:

Nurse reassures resident in nursing home.
Nursing care coordination improves a facility’s efficiency and care outcomes.
  1. Primary Care Coordination – To tackle the growing problem of America’s aging population, some healthcare providers use a “guided primary care” approach developed by Johns Hopkins University. This approach allows a specially trained registered nurse (RN) to be responsible for residents and patients with multiple chronic illnesses. Therefore, the registered nurse coordinates with the primary care provider and any specialty providers to develop a detailed care plan ensuring the entire care team is organized and updated with the latest resident-centered information. Guided care studies show that this approach provides a higher quality of care while simultaneously reducing healthcare costs.
  2. Acute Care Coordination – Residents and patients who require acute care are often in critical or emergency medical conditions. They need a complex level of care due to their situation. Emergency medical services or hospitals administer such care outside the patients’ or residents’ regular network. Medical errors can occur due to poor communication between healthcare providers in such circumstances. Therefore, acute care coordination prioritizes the transition of care, focusing on critical factors like open communication, follow-up visits, accurate prescriptions, and providing clear instructions for patients and residents. These combined actions help to reduce hospital readmissions and mortality rates.  
  3. Post-Acute/Long-Term Care Coordination – Senior residents in long term or post-acute care facilities often need multiple levels of care for physical disorders, mental disorders, or both. This means there are often transitions between the different care services, changes in medication, and care plan adjustments. Studies show that readmissions to either long term care or post-acute care facilities are common and contribute to the high mortality rate because of inadequate care transitions and poor communication between the healthcare providers. Therefore, all healthcare providers need to create and maintain a detailed care plan using effective nursing computer software stating what treatments have been administered and what care is necessary. 

Patient-Centered Care Coordination

In addition to nurse-led care coordination, long term care facilities have developed a method for using patient-centered care coordination, an approach devised by incorporating the resident’s needs, their family, and the facility. It takes into account the resident’s environment, feelings, and preferences. 

The key elements of patient-centered care can be reduced to the Four C’s: care, culture, communication, and collaboration. When a facility factors these elements into their comprehensive care plan, they make more empathetic clinical decisions while taking into consideration the resident’s values, opinions, and rights. 

Patient-centered care results in: 

  • Higher resident satisfaction, as the resident’s values and desires are acknowledged making them feel more valued
  • Increased job satisfaction among staff, as they take a greater sense of pride in their jobs
  • Better health outcomes with shorter recovery times, fewer emergency room visits, and reduced use of healthcare resources

The Impact of Coordinating Nurse Care 

Coordinating nurse care is only successful with strong leadership that understands the essence of care coordination. Klick believes that care coordination centers around “the right services at the right time, in the right order, and in the right setting.” This is achieved by recognizing that registered nurses are the first port of call for care coordination. After all, the nurses are on the floor, caring for the residents on a daily basis, so they understand the complexities of resident care and what resources are available.

Man in hospital receives support from nurse.
Successful coordinating nurse care requires strong leadership.

A 2011 Institute of Medicine report supports the view that registered nurses play a crucial role in coordinating nurse care. The report also argues that registered nurses should assume leadership roles in the coordination of care in nursing because of their strong problem-solving, innovation, and adaptable skills at multiple levels and settings. These skills give nurses strong foundations to administer excellent care coordination using their unique insights, valuable abilities, and experience. 

Furthermore, the report strongly opines that healthcare professionals at other facilities should liaise with nurses with open communication to devise better nursing care coordination strategies that will improve the quality of care given to residents. 

Other studies highlight the positive influence of nursing care coordination through nurse-led and patient-centered care coordination. Initiatives, like the American Academy of Nursing’s (AAN) Edge Runners program, highlight nurse-led programs that have proven to improve patient outcomes, decrease overall costs, and enhance satisfaction.   

The benefits of care coordination are the result of the experience and skills of a registered nurse that can develop, implement, and maximize an all-inclusive and interprofessional care plan focusing on the facility’s resources and residents’ needs and preferences. A nurse will also need to identify any potential barriers to care when evaluating a resident’s treatment adjustments. This coordinated care will support any changes in medical condition and account for any social support changes.

How To Maximize the Coordination of Care in Nursing 

Well-designed and targeted coordination of care in nursing is a consequence of the efforts of registered nurses who use their skills in cognitive decision-making, communication, problem-solving, and counseling to address the needs of the residents and identify any potential issues for the facility.  

Nurse gives resident a  cup of tea.
Successful coordination of care in nursing requires innovation and adaptability.

Even though successful nursing care coordination can improve a facility’s efficiency, safety, and quality of care, there are still obstacles to overcome. The current healthcare system is somewhat disjointed with poor communication between providers. This is a weak link that impacts the quality of care, readmissions, mortality rates, and finances.

Hence, more precise care coordination needs to occur to improve communication between healthcare providers, especially during care transitions. This is where effective nursing home software helps support care coordination between all relevant staff and healthcare providers by providing easy access to resident data. 

Moving to a long term care EHR eliminates illegible nursing documentation and provides more detailed and accurate data so healthcare providers can gain a comprehensive picture of what care and treatments have taken place so far. It also maximizes the quality of care by allowing healthcare providers to communicate with each other, thus understanding the resident’s real-time needs and medical conditions. 

For more on recent trends in long term care, read our blog and subscribe to the LTC Heroes podcast

Cindy Wong
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