Apr 21, 2023

Resources to leverage expertise in care coordination and care management

Recommendation 1.3 of the 2021 Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity report calls for developing mechanisms for leveraging the expertise of relevant nursing organizations in care coordination and care management. Care coordination and care management principles, approaches, and evidence should be used to create new cross-sector models for meeting social needs and addressing SDOH.

A group of graduate nursing students from from the Texas Tech University Health Sciences Center found resources and created the repository below that can help achieve this sub-recommendation.

Care Coordination Toolkit

Description: This toolkit can be used to by Accountable Care Organizations (ACOs) to learn from and come together to enhance their knowledge and skill sets regarding the population(s) that they serve.

Citation: Centers for Medicare and Medicaid Services. (2019). Care coordination toolkit. https://innovation.cms.gov/files/x/aco-carecoordination-toolkit.pdf

Rural Care Coordination Toolkit

Description: This toolkit consists of seven modules that are geared towards rural communities to help them with learning how to identify and implement care coordination program(s),and also provides additional resources and best practices to aid them with this process.

Citation: Rural Health Information Hub. (2023). Rural care coordination toolkit. https://www.ruralhealthinfo.org/toolkits/care-coordination

Care Coordination

Description: This resource explains what care coordination is, why it is important, and how you can apply this to practice.

Citation: Agency for Healthcare Research and Quality. (2018). Care coordination. https://www.ahrq.gov/ncepcr/care/coordination.html

Care Management

Description: This resource has information on how care management is interwined in advance care planning, chronic care management, behavioral health integration, and transtional care management. This resource has fact sheets and frequently asked questions for each type of care management listed above.

Citation: Centers for Medicare and Medicaid Services. (2022). Care management. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Care-Management

Care Coordination and the Essential Role of Nurses

Description: This resource does an excellent job with helping the nurse understand their vital role in care coordination. It also has wonderful reference links that lead you to take a deeper dive into how and why the nurse is so important in care coordination.

Citation: American Nurses Association. (n.d.). Care coordination and the essential role of nurses. https://www.nursingworld.org/practice-policy/health-policy/care-coordination/

Commission for Case Manager Certification

Description: Website has excellent resources and guidance for Case Management certification with a list of exam study materials that can bolster individual nurses skills. A complete 11 page reference list is available for download on the site and was last updated Jan 2023.

Citation: Commission for Case Manager Certification (CCMC) (2023, February, 14). About CCMC. https://ccmcertification.org/about-ccmc/ccmc