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This is the transcript for the Vila Health: The Nurse’s Role in Care Coordination. You can get information here.

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Introduction

Care coordination is one of the fastest growing and evolving trends in the nursing field. In order to be an effective care coordinator, it is important to understand the roles that case managers and other care coordination team members play in a health care setting. It is also valuable to understand how these roles have evolved—and continue to evolve— over time. In this activity, you will learn more about the role of care coordination in an acute care setting. Nursing homework help

After completing the activity, you will be prepared to:

• Summarize the roles that case managers and other team members play in care coordination.
• Contextualize care coordination and today’s care coordination trends historically.

Details

Congratulations! You have been just hired as a case management intern in the Care Coordination Department at St. Anthony Medical Center. Located in Minneapolis, St. Anthony is a 120-bed hospital in the Vila Health system, which operates facilities in several Midwest states. The Care Coordination Department manages patient cases throughout the entire hospital.

Since it’s your first day, your first task is to get oriented. Your preceptor will help you get started. To learn more about the roles that care coordinators play in nursing, you’ll be talking with experienced case managers, social workers, and other members of the team. You’ll also sit in on a coordination planning meeting.

Office

It looks like you have an email from Denise McGladrey, your new preceptor. Click the icon to read it.

From: Denise McGladrey
Subject: Your first day

Welcome to St. Anthony! We’re so glad to have you on the Care Coordination team. As you know, I am going to be your preceptor. My job is to help you transition into your new role as case management intern and to offer you support. You should feel free to come to me with questions.

I have several meetings today, so I won’t be able to meet with you until this afternoon. In the meantime, since this is your first day, I want you to learn more about your role by talking with some of the people with whom you’ll be collaborating. I’d like for you to ask them questions about the case management role and the skills you’ll need to be successful. Most of the people you’ll be talking to have a good deal of experience, so I’d also like for you to ask questions about how the field has evolved over the years.

I’ve gone ahead and scheduled two interviews with you: one with Vicki Vasquez, who, as you know, is the Director of Case Management here at SAMC. The other interview will be with Samantha Rockwell, an experienced social worker who you’ll be coordinating with quite a bit in the near future. You’ll also have the opportunity to schedule interviews with your choice of a number of other team members.

I’ll be catching up with you later. Have a great day!

—Denise

Schedule Interviews

It looks like you need to speak with Mackenzie, Crystal, and Joyce about this incident—and then find some strategies for motivating them to succeed. You should go talk with each of them now.

Seth Patterson

Case Manager

Can you please describe your role in the department?

Seth: I coordinate care for all kinds of people in the hospital. They tend to give me cases involving older adults, since that’s my background, but for the most part all the case managers need to be equipped to work with all kinds of cases. I worked with geriatric patients almost exclusively with another hospital. Other case managers come to me sometimes when they need geriatric resources or have questions about how to help elderly patients.

In your opinion, what are some of the most important things a new case manager needs to know?

Seth: Here’s a tip: make yourself a master list of phone numbers! I can help you get started with that. After a while, you figure out who to call at each insurance company when you really need to get something done, or who to call at various social service agencies to get accurate information about resources, and so forth. I can’t even tell you how much time my list saves me!

What are some of the biggest mistakes case managers make?

Seth: One of the biggest problems case managers have is with coordinating transfers from one facility to another—especially when you’re talking about older adults, because moving them can be very risky. When patients go to the wrong facilities, that can be traumatic for the patient and costly for the hospital. It’s important to do your research and find the best possible facilities for patients so they don’t have to be moved again. That can be a real challenge because of insurance issues… ugh! It’s incredibly frustrating when the best facility for someone isn’t covered by insurance. But that’s just part of our jobs…. negotiating stuff like that with insurance companies on behalf of our patients’ best interests. It’s also really important to figure out whether sending somebody home is a good idea. Sometimes home health care is the best solution, but sometimes it’s not, depending on the family situation and all kinds of factors you need to consider.

In your experience, how has care coordination changed?

Seth: Dealing with insurance companies and Medicare and federal regulations and all of that… it just gets more complicated all the time. I like to think that I’m an advocate for our patients, helping them navigate through all this red tape and regulation. If it’s this hard for me to navigate things, I can only imagine how hard it is for the patients—especially if they’re elderly or have language barriers and stuff like that.

What are the some of the most important trends in care coordination?

Seth: Electronic medical records are revolutionizing what we do. And overall this is a good thing. I mean, a big part of what we do is to try to prevent fragmentation of care, and EMRs make a world of difference with that. On the other hand, as someone who’s worked with elderly people, I know what a problem EMRs can pose to patients who aren’t technologically literate. I’ve heard and seen horror stories. One of the nurses at a clinic where I used to work, she told me about this elderly woman who had elevated blood sugar levels. Her manager wouldn’t let her call the woman to get a retest because the clinic wanted to push people into using the new patient portal. You know, because of meaningful use issues? If enough people didn’t use the portal, the clinic could lose funding. Well, this woman was in her 80s, and lo and behold, she never looked at her electronic record and wound up at the hospital with a blood sugar level over 600!

Nora Jackson-Green

Case Manager

Can you please describe your role in the department?

Nora: Oh boy, where do I even get started? I don’t want to sound melodramatic, but sometimes I feel like I’m a human life raft. The medical system is this massive sea of confusing information. And sometimes there’s dangerous sea monsters who are more interested in getting paid than helping a patient get to land. My job is to navigate the patients through all this choppy water so they don’t drown.

In your opinion, what are some of the most important things a new case manager needs to know?

Nora: Case managers need to know how to communicate with the patients and their families! They need to make sure that families truly have the resources they need to help care for a patient. It’s not enough to ask patients what they need, because a lot of times they don’t know what they need. Or they totally underestimate how much physical and emotional work goes into caring for a loved one. It’s our job to anticipate their needs before a crisis happens. And as Baby Boomers like me get older, it’s going to be more and more important to know how to help families navigate these kinds of situations. We’re not a society that’s set up to help people who are old and sick! So it’s up to us to make sure people get what they need.

What are some of the biggest mistakes case managers make?

Nora: Case managers really need to be on the lookout for red flags that something’s wrong, or that something’s not going to go smoothly. Because otherwise, patients who really need our help can fall through the cracks. We don’t always have a lot of time with the patients, so we need to pay attention to all kinds of details. If a patient is showing any possible signs of dementia, for example, that’s a red flag. We need to investigate further. If a patient is taking a potentially dangerous drug, or if they show signs of prescription drug dependency, we need to follow up and not just send that patient home. It’s kind of like being a detective, only you don’t know exactly what you’re looking for.

In your experience, how has care coordination changed?

Nora: Well, I think the whole health care system has changed in that there’s so much more emphasis on accountability. We have to prove we’re doing a good job. Care coordination has evolved with the emphasis on outcomes and quality. It used to be that care coordination was a more unofficial part of what nurses did. Now, it’s being recognized more and more as a critical job duty, and that’s because coordinated care leads to better outcomes.

What are the some of the most important trends in care coordination?

Nora: Like I said, the emphasis on outcomes and quality has really changed care coordination. We’re constantly being evaluated on patient outcomes. There are direct financial consequences for the hospital if our outcomes aren’t good. That means that care coordination is taken more seriously, because it absolutely has to be.

Vicki Vasquez

Director of Case Management

Can you please describe your role in the department?

Vicki: Well, the part of my job that I like the most is serving as a role model and mentor to the team members in this department. I’ve worked in care coordination for a long time. So if someone feels like they’re up against a brick wall and can’t figure out how to help a patient, I can put on my coach hat. I enjoy that. A more challenging part of my job is working with the bureaucracy to make sure that patients get what they need and that the hospital gets paid. Health care law and regulations change all the time. You’ll be shocked at how much they change. As the leader of this department I have to make sure I’m 100% on top of these changes—especially since St. Anthony is an Accountable Care Organization. The hospital is constantly evaluated on 33 quality indicators, and our ability to manage complicated cases is essential if we’re going to keep our rank up.

In your opinion, what are some of the most important things a new case manager needs to know?

Vicki: There’s a lot you need to know to be an effective case manager. One of the most crucial skills is problem solving. If you’re looking for a job where there are clear-cut answers in a guidebook, well, maybe you should be an accountant or something. Every case is like a puzzle that needs a unique solution, and a lot of times, even the best solutions need troubleshooting.

And a big part of learning how to solve these problems is looking at patients holistically. You know what I mean by holistically, right? That means you have to look at the whole situation and understand how all the parts of the situation fit together. You have to look at the whole picture—health history, psychological factors, family situation, financial situation, ethnic and religious factors. There are all kinds of barriers to care you can miss if you don’t look at how the factors fit together.

What are some of the biggest mistakes case managers make?

Vicki: I think different case managers tend to make different mistakes. Like I said, it’s really important to understand patients holistically. When case managers focus exclusively on medical issues to the exclusion of a patient’s family or social situation, that’s a big miss. And another serious error that case managers can make is exceeding their scope of practice. It’s very important not to overstep boundaries and make decisions that belong to physicians or other members of the team. And that’s an easy trap to fall into… like, for example, it can be very tempting to make a decision about changing a patient’s medication or dosage without consulting the primary physician. Maybe the physician is hard to reach that day, and maybe it seems very obvious to the case manager that a medication needs to be discontinued. But those kinds of decisions can lead to critical errors and liability issues. Case managers absolutely need to respect the primary physician’s role as the team lead. And sometimes, like it or not, they need to follow orders.

In your experience, how has care coordination changed?

Vicki: We’re starting to understand care coordination as a specialized job duty in a way that we didn’t before. There’s always been care coordination. Nurses did that as a part of their jobs, and they still do. But now we have full time case managers, and schools are offering coursework and formal training in care coordination.

What are the some of the most important trends in care coordination?

Vicki: Well, the health care system as a whole has gone through some major paradigm shifts. From the perspective of our work, I think the most important trend has to do with value-based payments. The hospital’s ability to receive reimbursement is directly tied to quality and patient outcomes—especially since we’re an Accountable Care Organization. Because of this, care coordination professionals play a crucial role in overseeing care to prevent errors. And overall, this is a positive change that improves patient care. But it does add a new level of pressure on case managers.

Samantha Rockwell

Social Worker

Can you please describe your role in the department?

Samantha: I consult with case managers to make sure that they’re considering all the social issues that impact a patient’s ability to get the care they need and to manage their care. I meet with patients and find out what’s going on in their lives… their financial situations, their family situations, possible barriers to care, anything really that might impact their ability to get care. I also work with case managers to help locate appropriate resources for clients

In your opinion, what are some of the most important things a new case manager needs to know?

Samantha: Case managers need to remember that care coordination is a transdisciplinary field. You have to be able to collaborate effectively with an interdisciplinary team. In fact, I would say that collaboration is possibly the most important skill that a case manager needs. You work with all kinds of people both inside and outside the hospital, and with insurance companies and families too. Nobody expects case managers to have all the answers, but they need to know who to work with and how to work with people to get these answers.

What are some of the biggest mistakes case managers make?

Samantha: When case managers overlook barriers to care, that’s a big problem. Sometimes case managers have blind spots when it comes to identifying these barriers. A few years ago, I worked with a case manager that just didn’t seem to understand transportation barriers. She would set up follow up care for patients way out in the suburbs. But a lot of our patients, they rely on public transit and can’t get out that far. Or they’re old and they don’t drive, or they don’t feel comfortable driving on freeways to new places. I don’t know why it never occurred to her that this could be a problem.

In your experience, how has care coordination changed?

Samantha: There’s a lot more awareness of the importance of looking at patients’ needs as they relate to sociological issues. This kind of awareness has been around informally for a long time—I mean, nurses have always been aware of these kinds of issues, and social workers have been employed by hospitals for a long time. But now social workers are being brought in more routinely to assess situations, as opposed to bringing us in later after something goes wrong. There are a lot of opportunities for social workers to go into care coordination right now, and that’s exciting.

What are the some of the most important trends in care coordination?

Samantha: Thanks to the Affordable Care Act, most people have access to medical care now. We used to see a lot of uninsured patients in the hospital, and now uninsured patients are the exception. This is a good change, of course—a very good change. But it also brings challenges. We’re working with people now who have little or no experience with the health care system. They need to be educated on how to work effectively with us. A lot of people don’t realize how things like deductibles work, and that health insurance doesn’t cover every single expense. And the Affordable Care Act also has led to more people in the system from lower socioeconomic groups. These people tend to have more barriers to care. We have to anticipate that some people will need more guidance through the system than others.

Lucas Branch

Diabetes Educator

Can you please describe your role in the department?

Lucas: I work with case managers to make sure that patients get the information they need about diabetes care and prevention. When appropriate, I provide patients with resources to help them manage their diabetes. Often I help patients who are diagnosed with a chronic condition and who also have diabetes, since that new condition might mean they have to make changes in their diabetes management plan. I also talk with patients who have prediabetes or risk factors.

In your opinion, what are some of the most important things a new case manager needs to know?

Lucas: From my perspective, case managers need to be aware that it’s critical to provide patients with accurate information—and explain to them how to use it. With diabetes, there’s so much misinformation out there. Some patients underestimate the danger of diabetes and think it’s no big deal. Others are completely terrified and think it’s a death sentence, and they don’t realize they have the power to manage it. And that’s true of other medical conditions as well. People rely way too much on Dr. Internet to get the information they need. A case manager needs to make sure that patients have real information they can use.

What are some of the biggest mistakes case managers make?

Lucas: As a team, it’s so important to do everything we can to prevent fragmentation of care. Fragmentation brings costs up and quality down, and it can be really dangerous. We need to make sure patients aren’t getting conflicting information or medication from different providers.

In your experience, how has care coordination changed?

Lucas: That’s a better question for someone like Nora, who’s been working in this field for so much longer than me! But even in the short time I’ve been here, I can see how much more care goes into managing patient transfers. We do a lot more investigating now to make sure patients are going to the right facilities.

What are the some of the most important trends in care coordination?

Lucas: The team mentality has made a really big difference. The idea that you bring in a diabetes educator, you bring in a dietician, you coordinate with a social worker…. that kind of interdisciplinary thinking leads to much better outcomes.

Karen Wu

Dietician

Can you please describe your role in the department?

Karen: I work with patients to make sure they have the information they need about nutrition in relation to their conditions. I educate, and give suggestions. A lot of patients have no idea what a difference changes in their diet and exercise can make. People often feel really overwhelmed by the prospect of changing their diet and health habits, so I help them come up with realistic strategies for making changes.

In your opinion, what are some of the most important things a new case manager needs to know?

Karen: I think case managers need to manage how overwhelming it can be for patients to be in the hospital. Someone gets diagnosed with a chronic or a terminal illness, and then they suddenly get all this information about all this stuff they need to do—medication, physical therapy, doctor’s appointments, changes in diet and exercise, so much! Case managers should help make the process feel more manageable for the patient, not less.

What are some of the biggest mistakes case managers make?

Karen: Not following up with patients. I mean, we don’t have unlimited time, so we can’t be checking up on people constantly. But we need to do things like schedule follow-up phone calls. I can’t tell you how many times a case manager has called and there was a mix-up of some kind.

In your experience, how has care coordination changed?

Karen: The fact that a dietician is brought in on such a regular basis is a big change! The role of nutrition used to be glossed over. Or doctors and nurses would tell people to make changes in their diet without giving them enough information about how to make realistic changes. These days, we work together as a team to identify all the things we can help the patient do to achieve a better outcome.

What are the some of the most important trends in care coordination?

Karen: I think there’s more awareness to barriers to care. That’s definitely true for nutrition. There are very real barriers that make it hard for people to get nutritious food, like food deserts. For people who rely on food shelves, it can be very difficult to meet special dietary needs. And culture and ethnicity can play a huge role too. Some traditional ethnic food is actually a lot healthier than the typical American diet, but that’s not always the case. Care coordination teams are getting better at identifying these kinds of barriers and identifying solutions.

Office

It looks like you have another email from Denise McGladrey, your new preceptor.

Patient Meeting Email

Email

From: Denise McGladrey
Subject: Patient meeting

I see you’ve been busy meeting with team members to learn more about care coordination roles and trends. Thank you so much for doing that!

I have another task for you that will help you get oriented. There’s going to be a meeting this afternoon to discuss care coordination strategies for a patient. Here’s the background: a 79-year-old man named Fred Decker was seen here two weeks ago with a badly infected toe. After the infection cleared up, he was sent home with instructions. Unfortunately, he and his family weren’t able to follow the instructions, and he returned to the hospital three days later with an infection that was even worse—and now he has sepsis. As you know, that’s a serious red flag. Care coordinators need to be seriously concerned with readmission rates, as these reflect poorly on the hospital and impact our ability to be reimbursed by Medicare.

Mr. Decker is responding well to antibiotics, thankfully. This afternoon, several members of the team are having a meeting to discuss his care.

Here’s what I want you to do. Go to the meeting, and just listen. At future meetings throughout your internship, you’ll offer your feedback, but for today, I just want you to be a “fly on the wall.” Afterwards, you’ll meet with me. I’ll ask you some questions about the meeting and provide you with some feedback.

Thanks for all your hard work!

Denise

Panel Discussion

It looks like you’ll be listening in on a meeting.

Vicki: So, Seth, you were the case coordinator who was working with Mr. Decker and his family. Can you tell me what happened?

Seth: Well, as you know, Mr. Decker came in with a badly infected toe. He was diagnosed with diabetes last year. It sounds like he hasn’t been treating it effectively.

Vicki: Why do you say that?

Lucas: I spoke with Mr. Decker and his wife. It sounds like he’s been forgetting to take his insulin. He said that’s only happened twice, but I got the sense from his wife that it happens fairly often. Plus they both told me his diet hasn’t changed much since the diagnosis. He’s lost about 10 pounds, which is great. But he’s still in the obese range.

Vicki: That’s too bad. Was the toe infection related to the diabetes?

Seth: It was probably a factor. He cut his toe while walking his dog. His wife washed the cut and put a bandage on it. But it got worse. A nephew finally took him to his primary physician, since he and his wife don’t drive on freeways anymore. The physician sent Mr. Decker to the hospital.

Vicki: So explain to me what happened when Mr. Decker came here the first time.

Seth: Mr. Decker was given antibiotics and the infection started to clear up after a two-day stay. Medicare wanted to send him home with antibiotics. We weren’t aware that his toe wound had progressed and he had developed a more resistant infection.

Vicki: That’s too bad. Samantha, what was your involvement in this case?

Samantha: I met with Mr. and Mrs. Decker. I was definitely concerned that Mr. Decker wouldn’t take the antibiotics if we sent him home. He also needed to treat the infection site twice a day. Mrs. Decker assured us that us that she would take care of her husband and make sure the infection was treated. But I was leery because it doesn’t sound like the diabetes or the original cut was treated very well.

Vicki: So why was he sent home?

Seth: Well, for one thing, we talked to the Deckers’ nephew—the one who drove him to the doctor and the hospital. He said that his wife was a stay-at-home mom and that she could stop by twice a day to take care of Mr. Decker. Apparently this couple lives in the same neighborhood as the Deckers. Also, the Deckers’ daughter was planning to fly in from California later that week to take care of him.

Vicki: Did that happen?

Seth: No. Apparently there was a last-minute emergency at the daughter’s workplace, so she wasn’t able to come. And it’s unclear to me how often the nephew and his wife stopped by.

Samantha: Yeah. I spoke with the nephew. Apparently his wife wasn’t happy about being volunteered for this situation. It sounds like she only stopped by a few times.

Vicki: So now Mr. Decker is back. It sounds like he is responding well to the new round of antibiotics.

Seth: Thankfully, yes. At first we thought an amputation might be necessary. But he’s doing remarkably well. He might be able to go home next week—except that we know that’s not a realistic option.

Vicki: So what’s next?

Samantha: The Deckers don’t have the resources to pay for much that Medicare won’t cover. A rehabilitation center might be a good option, but it will be a challenge to find one they can afford. Other options would be home health care or an outpatient infusion center.

Vicki: Seth and Samantha, what are your thoughts about the outpatient infusion center?

Seth: At this point, I think that’s the best option. Mr. Decker doesn’t need rehabilitation. He just needs someone to administer the antibiotics.

Samantha: I actually think a skilled nursing facility might be the better option. We’ve seen that the Deckersaren’t able to handle this themselves, and that they don’t have a good enough support system to help. The infusion center would only help with the antibiotics. We need to make sure the infection site is cared for and that he gets some help with his diabetes as well.

Seth: But that’s an expensive option they may not be able to afford—and I don’t think that level of care is necessary.

Samantha: But I just can’t picture sending Mr. Decker home yet. I’m afraid he’ll wind up back here again—or worse.

Post Discussion Interview

So, you were a fly on the wall for the meeting about Fred Decker. It looks like he’ll be cleared to leave the hospital next week. The team needs to recommend a course of action for him. What do you think should happen next?

That’s certainly one option. But what if the Deckers can’t afford it?

If the Deckers might have difficulty affording a rehabilitation facility, what step do you recommend next?

Research options. Look for a rehabilitation facility that they can afford.

Good point. Forget it—let’s go with the outpatient infusion center.

That’s certainly one option. Let’s assume the outpatient infusion center is covered by Medicare. Do you have all the information you need before recommending this option?

In the conversation among your colleagues, Seth favored the outpatient infusion center. What step do you recommend next?

Seth is right. Send Mr. Decker to the outpatient infusion center.

There’s an important question that nobody asked.

I would definitely do this. It sounds like Mr. Decker might not do so well at home yet. Make some phone calls. However, be prepared for the possibility that they won’t be able to afford a rehabilitation facility. You’ll need to consider other options as well—like an outpatient infusion center.

Do you think Seth made the right choice in recommending that Mr. Decker be sent home after his first hospital visit?

Yes. There was reason to believe that Mr. Decker had enough help—his daughter was coming, and his nephew said they would help.

No. he should have stayed in the hospital.

Don’t give up so easily. Make some phone calls and look for a facility they can afford. I have my doubts that this patient is ready to go home yet. You may be right, and you might need to go with the outpatient infusion center, but see what’s out there first.

Do you think Seth made the right choice in recommending that Mr. Decker be sent home after his first hospital visit?

Yes. There was reason to believe that Mr. Decker had enough help—his daughter was coming, and his nephew said they would help.

No. he should have stayed in the hospital.

I agree that the outpatient infusion center is probably a good choice. But nobody asked about transportation. Remember—the Deckers aren’t driving much anymore, and it doesn’t sound like they have a reliable neighbor or relative to take them. Before recommending this option, you should research medical transport companies to find out if this is a good option for getting Mr. Decker to his appointments. Or find out if there’s a facility close to their home that Mrs. Decker feels comfortable driving to.

Also, I wouldn’t give up on the rehabilitation facility idea. Call around and see if you can find a facility Mr. Decker can afford. Sending him home right now might not be the best idea if there’s an affordable alternative.

Do you think Seth made the right choice in recommending that Mr. Decker be sent home after his first hospital visit?

Yes. There was reason to believe that Mr. Decker had enough help—his daughter was coming, and his nephew said they would help.

No. he should have stayed in the hospital.

That’s right. I agree that the outpatient infusion center is probably a good choice. But nobody asked about transportation. Remember—the Deckers aren’t driving much anymore, and it doesn’t sound like they have a reliable neighbor or relative to take them. Before recommending this option, you should research medical transport companies to find out if this is a good option for getting Mr. Decker to his appointments. Or find out if there’s a facility close to their home that Mrs. Decker feels comfortable driving to.

Also, I wouldn’t give up on the rehabilitation facility idea. Call around and see if you can find a facility Mr. Decker can afford. Sending him home right now might now be the best idea if there’s an affordable alternative.

Do you think Seth made the right choice in recommending that Mr. Decker be sent home after his first hospital visit?

Yes. There was reason to believe that Mr. Decker had enough help—his daughter was coming, and his nephew said they would help.

No. he should have stayed in the hospital.

You may be right. Should Seth have done more to make sure that Mr. Decker had enough care at home?

Do you think Seth should have done more?

No. It’s too bad things went wrong, but Seth covered all his bases.

Seth should have investigated the situation further.

That might have been the best choice if it weren’t for financial considerations. The hospital can’t keep people here indefinitely. Can you think of some other alternatives?

What alternative to an extended hospital stay do you recommend?

A home health care service should have been investigated.

He could have been sent home, but Seth should have followed up to make sure he was getting the care he needed.

On the one hand, case managers can’t be expected to anticipate every possible problem—like the last-minute work emergency that made it impossible for the daughter to fly out here. On the other hand, I do think Seth could have investigated a little further. He could have spoken with the daughter to make sure her flight plans were concrete—and followed up to make sure she arrived. And I especially think Seth could have talked to the nephew’s wife, instead of relying on the nephew’s promise that his wife would help out.

I agree. He could have contacted Mr. Decker’s daughter and his nephew’s wife. Those were the two people who were supposed to provide assistance, but Seth didn’t speak to them personally.

That’s a good idea. It might not have been affordable, but I agree that option could have been explored. There was enough evidence that Mr. Decker and his wife were not able to care for his infection alone, and no proof that anyone reliable was available to help them.

That’s a good choice. If Seth had followed up on this case, he would have discovered that home care was not working. He then could have explored other options, like a rehabilitation facility or an outpatient infusion center.

Conclusion

You have completed the Nurse’s Role in Care Coordination activity. Now that you have spent your first day on the job at St. Anthony Medical Center, you should be able to:

• Summarize the roles that case managers and other team members play in care coordination.
• Contextualize care coordination and today’s care coordination trends historically.