Running head: CARE COORDINATION AND TRANSITION OF CARE

The Role of Nurse Practitioners in Care Coordination and Transition of Care: How Nurse
Practitioners Can Make a Difference in the Outcomes of Their Patients
Courtney Queener
7/7/15
State University of New York Polytechnic Institute

The Role of Nurse Practitioners in Care Coordination and Transition of Care: How Nurse
Practitioners Can Make a Difference in the Outcomes of Their Patients
Care coordination and transition of care are two very important aspects of effective
healthcare. Nurse practitioners play a valuable role in coordinating the care of their patients and
helping their patients transition from one facility to another or to home. The effectiveness of
well-planned coordination of care has been proven over the years by evaluating the outcomes of
nurse-practitioner led transition of care programs. These programs are gaining popularity and are
a way for nurse practitioners to showcase their skills and knowledge for the good of their
patients. This paper will discuss the significance of coordination of care and care transition,
provide a review of literature relevant to the subject, and discuss the implications for the nursing
profession.
Care Coordination and Care Transition in Healthcare

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Care coordination is a term that refers to the integration of health and social care services
for patients. Care coordination has many components that are vital to the success of the
healthcare. Care coordinators work with the patient and their care providers to ensure that a
quality, integrated and personalized care plan is implemented. They monitor services provided to
ensure that they are delivered in a timely fashion, are effective, and achieve what they were
intended to do. Care coordination also involves maintaining contact with the patient during
hospital stays, arranging for discharge, and facilitating communication between multiple
healthcare agencies and professionals and overseeing discussions as needed (Medical Dictionary,
2015). Carefully planned organization of care allows for patients to feel more confident in their
healthcare providers ability to care for their needs and to prevent the patients from undergoing
unnecessary testing due to a higher level of communication between the patients different care
providers.
The term transitional care is defined as a set of actions designed to ensure the
coordination and continuity of health care as patients transfer between different locations or
different levels of care within the same location. Representative locations include hospitals, subacute and post-acute nursing facilities, the patients home, primary and specialty care offices, and
long-term care facilities (The Care Transitions Program, n.d.). Transitioning to a new facility or
returning home from the hospital can be a very difficult time for patients. After transition,
patients are often confused about their medications, what they should continue taking and what
they should discontinue use of. When transitioning to another healthcare facility, there may be
some discrepancies between the patients current medication list and the information sent to the
new facility and patients may not receive an important medication or may receive a medication
that is no longer necessary or could now be harmful to the patient (Ornstein, Smith, Foer, LopezCantor, & Soriano, 2011). Another obstacle with transition of care is follow-up. Patients

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returning home may not complete the recommended further evaluation or may fail to follow up
on outstanding test results. Likewise, when transitioning to another care facility, these test results
may become lost in the process and never received by the care providers (Ornstein et al., 2011).
These inadequacies with the transition of care can cause patients and family members to become
dissatisfied with their care and can lead to increased hospital readmissions and use of medical
services. When the transition of care is not coordinated properly, patients are not receiving the
most efficacious care available and may be subject to unnecessary testing, costs, and harm.
Nurse practitioners are becoming more involved in the coordination of care and transition
of care of their patients and have a lot to offer to patients requiring complex care. There are
various obstacles to optimal care delivery when transitioning including poor communication
between clinicians, inadequate preparation of patients and caregivers, unmet care needs,
medication errors, missed diagnostic results, and unplanned healthcare use (Schoenborn,
Arbaje, Eubank, Maynor, & Carrese, 2013). The role of care coordinator is a very important one
that has many components. NPs in this role can communicate with the patient and family and
provide education regarding the discharge plan. They are also able to provide an assessment of
the patients discharges needs and need for support at home. They communicate with
multidisciplinary staff regarding the discharge plan and post-discharge care of the patient,
including communicating with clinicians in other settings who care for the patient. NPs can help
the patient and care providers with medication reconciliation and provide patients with discharge
instructions and information on post-discharge follow-up and care (Schoenborn et al., 2013). All
of these components help to ensure that the patient is receiving the best possible care and is more
prepared to care for themselves after being discharged from the hospital. These efforts can have a
great effect on the patients health after discharge and on hospital readmission rates. It can also
have a positive effect financially for both the patient and the hospital system.

CARE COORDINATION AND TRANSITION OF CARE

Review of Literature
The effectiveness of well-organized coordination and transition of care has been well
documented over the years. Nurse practitioners play a crucial role in the coordination of care of
their patients and have proven to be an important asset in the implementation of transitional care
programs. There have been many studies conducted evaluating the effectiveness of these
transitional care programs. These studies show that efficient coordination and transition of care
allow for better outcomes for patients and can help to decrease hospital readmissions
significantly.
In an article by Hendrix et al. (2013), the authors proposed to describe the development,
implementation and preliminary results of a clinical demonstration program, Transitional Care
(TLC) Partners, which supports the transition from hospital to home for older adults. The TLC
Partners program was initiated at Durham Veterans Affairs Medical Center (VAMC) and is based
on Naylors Transitional Care Model. This model provides a framework for planning and
organizing a structure to provide comprehensive in-hospital planning and home follow-up for
chronically ill high-risk older adults in order to streamline plans of care and prevent decline of
health status (Hendrix et al., 2013). The TLC Partners program is led by a nurse practitioner and
provides health care to patients after discharge from the hospital for a time-limited period.
In the first 5 months after the program was initiated, TLC Partners received 80 consults.
Of these 80, 54 veterans were enrolled in the program, whereas 26 were ineligible for enrollment
for one of the following reasons: being discharged to a facility, living outside of the 35-mile
radius, being too young in age, were already discharged from the hospital before the TLC NP
could do a hospital visit, or being too sick (Hendrix et al., 2013). An additional seven patients
were removed before the first home visit because home visitation was refused or because the
patient died (Hendrix et al. 2013). The authors evaluated data collected from hospital and ED
visits of the 47 remaining TLC patients up to 90 days after being discharged from the program.

CARE COORDINATION AND TRANSITION OF CARE

For comparison, they also tracked patients who were referred to the TLC program but did not
enroll. The patients enrolled in the TLC Partners program experienced consistently lower rehospitalization when compared with the non-TLC patients. The study also measured the effect on
caregivers by administering the Preparedness in Cargiving and Zarit Burden scales to
participating caregivers. Of the participants, 43% had an increase in their total preparedness
scores and 53% had a decrease in caregiver burden at the end of the TLC (Hendrix, 2013). The
success of the TLC Partners program is an example of how nurse-led transitional care models
can be adapted to the needs of different patient populations and how their effectiveness can be
evaluated (Hendrix, 2013).
In an article by Ornstein et al. (2011), the authors discussed a nurse practitioner based
transitional care program designed for the homebound patient population after hospitalization
developed by the Mount Sinai Visiting Doctors Program (MSVD). MSVD patients are primarily
older (mean age 81) females (74%) who have multiple chronic health conditions. The majority of
the patients require help with five or more activities of daily living and can be a great burden to
their caregivers (Ornstein et al., 2011). This two year study described the program which was
designed to improve coordination and continuity of care, reduce readmissions, garner positive
feedback, and demonstrate financial benefits through shorter length of stay, lower cost of
inpatient stay, and better documentation of patient complexity (Ornstein et al., 2011). Nurse
practitioners were chosen to lead the program because they are less expensive than physicians
but have more extensive clinical training than nurses (Ornstein et al., 2011).
The NPs would make early contact with MSVD patients who were admitted into the
hospital or ED and communicate frequently with the hospital staff caring for the patient. The
information discussed included the patients medical history, reason for admission, advanced
directives, home medication list, and need for social service. The NP would visit the patient daily

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or every other day during their inpatient stay, depending on census. The NP would document
pertinent information in the patients EMR and communicated frequently with the PCP. When
planning for discharge, the NP would work closely with the hospital staff to understand the
changes made to the patients treatment plan, the test results, and the services arranged for after
discharge. Within 3 weeks after discharge, the NP would make a single home visit. During this
time, the NP performed a physical assessment and addressed whether the reasons for admission
were resolved, if there were any new problems, went over the patients medications, evaluated
the appropriateness of home care services and assessed the adequacy of patient and caregiver
education (Ornstein et al., 2011).
The researchers conducted a mixed-methods evaluation to determine provider feedback
and the feasibility, effectiveness and cost of the program. The effectiveness of the project was
measured by evaluating the effect of the intervention on length of stay (LOS), case-mix index
(CMI), readmission rates, and hospital financial outcomes using a pre/post design (Ornstein et
al., 2011). During the 27 month time period, 532 MSVD patients were hospitalized. 53% had
only one admission and 47% had repeat admissions. Results showed that the LOS for admissions
that occurred during the intervention period were not significantly shorter during the study
period than before the program (Ornstein et al., 2011). However, CMI was significantly different
between the control and intervention group; CMI increased from 1.25 to 1.35 during the
intervention period. Also, during the intervention period there were significant increases in net
revenue, support costs and direct care costs (Ornstein et al., 2011). The provider groups caring
for the patients also expressed positive feedback stating that the progress notes written by the NP
were a huge relief because they were able to get some real information about their patients
hospitalization. The text states that the inpatient and outpatient providers noted that the liaison
program saves time, improves inpatient management, and smooths the discharge process.

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Nevertheless, for operational outcomes such as LOS and readmission rates, it was not possible to
demonstrate significant differences between the pre-study period and the intervention period
(Ornstein et al., 2011).
An article by Naylor et al. (2013) evaluated the impact of the Transitional Care Model
(TCM) to address the needs of chronically ill older adults throughout acute episodes of illness.
The TCM is a model designed to improve the outcomes of chronically ill patients making
frequent transitions from hospital to home. The model uses an advanced practice nurse (APN) to
provide inpatient planning and post-discharge follow-up, using an evidence-based care
management approach (Naylor et al., 2013). The design of the study was a prospective, quasiexperimental study of 172 Aetna Medicare Advantage members who received the TCM. The
study compared baseline and post-intervention data on health status and quality of life. Member
and physician satisfaction were also assessed. In addition, health resource utilization and cost
outcomes were compared to a control group throughout the year. Inclusion criteria for
participants included all cognitively intact, community-based older adults (aged 65 or older)
coping with common chronic illnesses who were enrolled in Aetnas Medicare Advantage in the
mid-Atlantic region and were participants in Aetnas geriatric telephone case management
program (Naylor et al., 2013). Participation in the program was completely voluntary after
information concerning the program had been sent to both the patient and their PCPs. For each
member in the TCM group, a control member was selected by exactly matching on primary
diagnosis and gender, while matching within specific ranges for age, number of hospitalizations
in prior 6 months, number of co-morbid conditions, a disease severity score (Aetnas algorithm)
and index enrollment date (Naylor et al., 2013).
One hundred and seventy two members were enrolled in the TCM program to compile
the final sample. When selected health status variables were compared before and after TCM,

CARE COORDINATION AND TRANSITION OF CARE

significant improvements were identified in functional status, depression, symptom status, selfreported health and quality of life (Naylor et al., 2013). Interviews with the members revealed
an overall high level of satisfaction with TCM (a 9.6 out of 10 for overall satisfaction). There
was a significant reduction in hospital re-admissions at the 3 month period among the TCM
members when compared to the control group. The 25% decreased in readmissions at this period
was accompanied by a 28% reduction in total hospital days. However, there was not a statistical
difference in re-admissions at the 6-month and 12-month mark (Naylor et al., 2013). The study
also showed a significant decrease in healthcare costs for the TCM members ($439 per member
per month at the 3-month mark and $181 per member per month at 52 weeks) (Naylor et al.,
2013).
Implications for Nursing Practice
The increasing role of nurse practitioners as care coordinators has many implications for
the future of nursing practice. The growing number of transitional care programs led by
advanced practice nurses means increased job opportunities of nurse practitioners. It is also an
opportunity for nurse practitioners to showcase their talents and value in the healthcare
community. Nurse practitioners are a particularly fit for the role of care coordinator because they
possess the knowledge and assessment skills needed to perform effectively. NPs are also trained
to provide holistic care and to anticipate patients needs. Betz and Redcay (2005) state, nurses
are particularly well suited to serve in these roles because they possess specialized knowledge
and skills to assess, intervene, and evaluate the long-term ramifications of living with a special
healthcare need. They go on to say Also, unlike social workers, advanced practice nurses can
adapt their knowledge of the chronic disease or disability to the daily living situations and
advocate for services such as reinforcing learning for managing the treatment regimen,
recommendations for health related accommodations in social situations, and making referrals to

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adult healthcare providers (Betz & Redcay, 2005). As the advanced skill set of nurse
practitioners becomes increasingly more recognized in the healthcare community, the more
opportunities for advanced practice nurses will arise.
Conclusion
Effective care coordination and transition of care are aspects of healthcare that have come
a long way in recent years but still require more attention and fine-tuning. The exceptional
knowledge and skills possessed by nurse practitioners are allowing them to become held in
higher regard in the healthcare community and opening up new and exciting career opportunities.
Leading transitional care programs such as the ones discussed within this paper is one of the
ways in which advanced practice nurses are able to prove their value in the healthcare
community. These programs are geared towards providing better outcomes for patients including
less hospital readmissions, fewer inpatient hospital days, clearer understanding of discharge
instructions, better medication management, and increasing the use of community resources
available to patients and their caregivers. Nurse practitioners are very well suited to provide
these valuable services to patients and are making a significant difference in the quality of life
and health of their patients.

References

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Betz, C., & Redcay, G. (2005). Dimensions of the transition service coordinator role. Journal
For Specialists In Pediatric Nursing, 10(2), 49-59.
Hendrix, C., Tepfer, S., Forest, S., Ziegler, K., Fox, V., Stein, J., & ... Colon-Emeric, C. (2013).
Transitional Care Partners: a hospital-to-home support for older adults and their
caregivers. Journal Of The American Association Of Nurse Practitioners, 25(8), 407-414.
doi:10.1111/j.1745-7599.2012.00803.x
Medical Dictionary. (2015). Care Coordination. Retrieved from http://medicaldictionary.thefreedictionary.com/care+coordination
Naylor, M. D., Bowles, K. H., McCauley, K. M., Maccoy, M. C., Maislin, G., Pauly, M. V., &
Krakauer, R. (2013). High-value transitional care: translation of research into practice.
Journal Of Evaluation In Clinical Practice, 19(5), 727-733. doi:10.1111/j.13652753.2011.01659.x
Ornstein, K., Smith, K. L., Foer, D. H., Lopez-Cantor, M. T., & Soriano, T. (2011). To the
hospital and back home again: a nurse practitioner-based transitional care program for
hospitalized homebound people. Journal Of The American Geriatrics Society, 59(3), 544551. doi:10.1111/j.1532-5415.2010.03308.x\
Schoenborn, N. L., Arbaje, A. I., Eubank, K. J., Maynor, K., & Carrese, J. A. (2013). Clinician
Roles and Responsibilities During Care Transitions of Older Adults. Journal Of The
American Geriatrics Society, 61(2), 231-236. doi:10.1111/jgs.12084
The Care Transition Program. (n.d.). The Care Transition Program: Health Services for
Improving Quality and Safety During Care Hand-Offs. Retrieved from
http://www.caretransitions.org/definitions.asp