Care Coordination Annual Report 2018 – 2019 Lori Popejoy, PhD, APRN, GCNS-BC, FAAN Mary Hook, PhD, RN-BC

Care Coordination Definition: “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services.” (American Nurses Association , 2012)

Purpose To identify shareable and comparable data across settings to support care coordination activities and improve patient outcomes.

Key Priorities Identify data elements (e.g. demographics, risks, SDOH, etc.) used by care coordinators for patient care. Identify documented care coordination activities. Explore opportunities to gather care coordination data elements used across settings.

Activities Work with the Standardizing the Nursing Admission History and Screening to Reduce Documentation Burden Identify data elements for care coordination activities Networked with Care Coordination Researchers Sheila Haas, PhD, RN, FAAN (Dean & Professor Emeritus, Loyola University) Beth Ann Swan, PhD, CRNP, FAAN (Professor Thomas Jefferson University) American Academy of Ambulatory Care Nurses (AAACN) to complete work identified at the Care Coordination Summit (2018). Plan to learn more about how AAACN and their associated organizations envision using the electronic health record and tools such as Better Outcomes for Optimizing Safe Transition (BOOST) related data elements to stratify patients and support care coordination. Work in progress

Lessons Learned: Care Coordination: 2018-2019 Many “people” are working on care coordination. Recognized need to collaborate with other groups: Participating in the Standardizing the Nursing Admission History and Screening to Reduce Documentation Burden Collaborating with Nurse Researchers associated with the American Academy of Ambulatory Care Nurses (AAACN) – held a summit last year and are working to strengthen the role of nurses in Care Coordination Transition Management (CCTM).