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Medical-surgical nurses practice in an increasingly complex healthcare environment with many older, chronically ill patients. These chronically ill patients often have five or more chronic conditions, requiring multiple medications. If this scenario sounds familiar to you, then you also know many of these patients and their family members have difficulty understanding how to coordinate the best care for the patient. Hence, care coordination and transition management (CCTM®) are vital roles of the medical-surgical nurse. The Agency for Healthcare Research and Quality defined care coordination as 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 healthcare services" (McDonald et al., 2011, p. 4). Care coordination is more than care navigation or case management. It requires interprofessional collaboration, most often with the nurse being central to the process.
Those of you who have been nurses for a long time know medical-surgical nurses have been coordinating care before this new terminology arose. However, care across the continuum has become increasingly complex and electronic health records do not possess the interoperability for the exchange of information that would be helpful for CCTM. Therefore, we are the ones engaging with the physicians, physical therapists, occupational therapists, social workers, dieticians, pharmacists, the patient's family/caregiver, and the patient. Care coordination was identified by the American Nurses Association (2012) as a core professional standard for all registered nurses. However, nurses continue to lack the knowledge and skills to perform the level of coordination required with the complexity of patients we serve in a confusing healthcare environment.
Transition management is inexorably linked with care coordination. Transition management is defined as a "broad range of services designed to ensure health care continuity, avoid preventable poor outcomes among at risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another" (Naylor,...