In the 2015 report Policy Agenda for Nurse-Led Care Coordination, published jointly by the American Academy of Nursing and the American Nurses Association, it was noted that “Nurses have been and continue to be pivotal in the development and delivery of innovative care coordination practice models.” As innovative models are implemented into the workflow of coordinating patient care, primary clinical care staff must continue to be knowledgeable and have the skills and abilities to use them effectively.
The Illinois Critical Access Hospital Network (ICAHN) organized a Care Coordination Certificate class for rural health care coordinators which educated students on the "Seven Domains of Care Coordination in the Primary Care Setting" by Kristy Baker, APRN-CNP, a Duke-Johnson & Johnson Nurse Leadership Program Fellow. The program is designed to improves care coordination for patients with chronic conditions, behavioral health issues, and teaches healthcare workers how to incorporate health promotion into their practice.
Amanda Johnson, LPN at Memorial Hospital's Rural Health Clinics took the 16 week on-line course and successfully completed her education with an ICAHN Care Coordination Certificate. During the course, Johnson learned how to improve care for her patients with multiple conditions and create a "care team" approach. By utilizing different resources throughout the community she is able to promote the patient to utilize a healthier lifestyle.
"Care coordination keeps patients active in their care, assists them with reaching goals they help set, encourages making healthy informed decisions and focuses on proactive care,"
explains Johnson. The course provides healthcare workers with the skills and understanding to better help the patient as a whole.
Extensive literature is studied during the program that teaches population health management, comprehensive assessment and care planning, motivational interviewing, interpersonal communication, and coaching techniques to prepare the coordinator for working with a wide spectrum of individuals with different care needs and temperaments. The patient needs to trust that the coordinator has their best interest in mind and feel that they have a voice in their care. The later part of the course focuses on the tools and resources needed to properly coordinate the best care including: health insurance and benefit services, identifying community resources, developing preventative care plans, and understanding advanced care planning.
Throughout the course Johnson had the opportunity to connect with other care coordinators and learn about their processes. "We were able to use real patient situations and help them to reach health goals." Students also learned about resources that can be used in their rural communities.
Memorial Hospital encourages every patient to play an active role in their healthcare. Working with trusted Care Coordinators the patients are able to feel confident that they have an entire team helping them to achieve their health and wellness goals. They work with their providers and coordinators to develop a plan and then have the support they need to execute it and live a healthier, fuller life.
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