1. Maughan, Erin PhD, MS, RN, APHN-BC, FAAN
  2. Green, Angela PhD, RN, CPHQ, FAHA, FAAN
  3. Henderson, Kristi DNP, APRN, FAEN
  4. Ching, Joan MN, RN, CPHQ
  5. Kuyl, Marni MS, BSN, RN
  6. Noonan, Melinda DNP, RN, NEA-BC
  7. VanDyke, Yvonne MSN, RN
  8. Team IMPaCT Executive Nurse Fellows (2013) Cohort, Robert Wood Johnson Foundation, Princeton, NJ.

Article Content

Care coordination and interoperability are current "buzz" words in healthcare. Nurses are key players in care coordination, particularly when transitioning patients from one area to another, including the community. Current care is fragmented or siloed, resulting in preventable medical morbidity, readmissions, declining functional status, and dependence on others for care. This is very costly, with an estimated cost of failures in care coordination of $42 billion to $45 billion in 2011 alone.1


Technology exists to support an integrated approach to care but is often not utilized. Further, electronic healthcare records (EHRs) across settings lack interoperability, and many community providers do not have EHRs. Few opportunities exist for providers, payers, and technology to interact to address these complex issues together. Seven Robert Wood Johnson Executive Nurse Fellows (2013 Cohort) (Team IMPaCT) organized a care coordination summit as part of their project. Team IMPaCT consisted of nursing leaders from various healthcare arenas, including school health, acute care, public health, and academic education. A central goal of the summit was to improve understanding and communication between hospital and community. Members of Team IMPaCT conducted interviews and focus groups with patients, families, and healthcare professionals to gain insider knowledge on transitions in care (see Table 1 for common themes of the interviews and focus groups). This was followed by a national summit engaging providers, payers, technology, and the community using liberating structures methodology to generate actionable prototypes and projects to facilitate improved transitions in care.

Table 1 - Click to enlarge in new windowTable 1 Results of Pre-Summit Interviews and Focus Groups


Patients receive care in numerous settings and systems and interact with multiple providers and payers. The settings, systems, providers, and payers all too often function independently, creating silos that negatively impact patient care and patient care outcomes. Historically, these systems worked independently of one another because funding and mandates differed for each group. However, the Patient Protection and Affordable Care Act (ACA) placed increased emphasis on changing healthcare delivery to meet the needs of patients.2 The ACA specifically emphasized the need for improved care coordination with a population/community approach for addressing patient needs across the life span. These community health providers should include nontraditional partners such as housing, grocery stores, schools, and job placement. Coordination is needed among traditional acute care health providers, public health, and the community to use resources effectively and to ensure that individuals receive coordinated care and do not fall through the cracks created by the siloed systems of care. Further, the current state is very difficult for patients and families to navigate alone.3 Care coordination is an umbrella term that includes case management and transition, both of which are critical. While nurses play a critical role in all aspects of care coordination,3 this project focused on care transitions from one setting or provider to another.


To support transitions in care, the ACA recommended that patients should be discharged (from acute care) with information that eventually should be electronic, include community resources, and allow the patient to view his/her own records online. In addition, ACA highlighted technology as a main component of a successful healthcare system for patients and providers.2 The Office of the National Coordinator (ONC) was established to assist healthcare teams to achieve compliance with the Centers for Medicare & Medicaid Services EHR incentive program, commonly known as "meaningful use." The "meaningful use" program, in part, provides incentives for the development and interoperability of EHRs for health information exchange.4 The highest rates of adoption of EHR is in large practices and academic medical centers, but only 14% indicate that they currently exchange healthcare information with other providers.5 To date, the efforts of the ONC and vendors have focused on acute care, which may partly explain why the adoption of EHRs by providers in community settings lags behind.


The use of technology for care coordination expands beyond EHRs and health information exchanges. It includes structure and process for telehealth to bring live consultation and care to groups that otherwise lack access to qualified providers, such as rural and vulnerable populations. It also includes mobile technology, self-service kiosks, wearables, and other technology that can provide patient information to providers or provide access to providers for patients.


Finally, in the midst of healthcare reform, the Institute of Medicine and Robert Wood Johnson Foundation's Future to Nursing Report called for nurses to work to their fullest potential and be leaders in transforming healthcare.6 Of all providers in the system, across settings, nurses have the most interaction with patients and thus need to be full partners in health reform. This is particularly true for reform intended to improve transitions in care.


Many groups have identified the need for improved care coordination using technology and are making strides in adoption and implementation. Yet, these groups often do not coordinate their own efforts. Team IMPaCT organized a national summit, held on March 30, 2015, at the Kaiser Permanente Center for Total Health in Washington, DC. The purpose was to generate national, cross-sector dialogue on using technology to improve transitions in care and to generate innovative prototypes for future action.



Fifty individuals attended (including the project team), with representation from technology (16%), consumers (2%), advocacy groups (16%), payers (8%), policymakers (14%), providers/health systems (22%), and other (22%). The summit utilized liberating structures7 to create dialogue, break down barriers, and discover hidden solutions. Key themes of the summit included (1) the importance of human/patient/consumer centeredness, (2) the importance of interoperability within and across organizations and sectors, and (3) the importance of communication. The importance of seeing patients as more than a problem to solve was foundational to the day's work.


The day began with a discussion regarding what would increase the likelihood of patients experiencing a failure in transitions in care. The answers helped participants stop and think about current systems. This was particularly helpful in creating a space for innovation by helping the group identify and deconstruct structure and process that create vulnerability among patients and barriers to seamless transitions in care. Participants were able to identify counterproductive behaviors and structures to eliminate, which included the following:


* Using "us and them" language for different subspecialties in nursing. We are all part of the same system.


* Lack of partnerships between public health and primary care


* Viewing telecommunication as a technology issue


* Insurance plans failing to reimburse for telehealth


* Policies and processes that are designed without consideration for the end user and community


* Treating patients and families as outsiders with needs versus active members of teams with both needs and assets


* Failing to listen


* One way communication between provider and patient


* Highly expensive, complicated systems that are proprietary


* Accessibility issues


* Failure to evaluate


* Patients responsible for care management



From this discussion, the facilitator guided participants into more constructive liberating structures techniques7 that eventually identified top innovative ideas for the group to begin developing prototypes. The top 10 ideas included the following:


* Create a multidisciplinary student health collaboration


* Develop a patient record system that follows the patients as they move through different health plans and providers.


* Focus the model of care on the nonpaid caregiver (volunteers and family members).


* Fund a national patient portal that allows patients to create their own longitudinal health record.


* Create a care transition platform whereby all entities involved in patient care can communicate.


* Create an information layer that leverages all the data collected and presents them in a way that is actionable at the point of decision making.


* Engage the end user (patient and providers) from the beginning of identifying solutions of care transition challenges.


* Read and know the patient's full name and use it every time.


* Engage community-based organizations to assist the populations they serve in using.



Finally, individual participants identified ideas that they wanted to move forward, and the remaining participants self-selected into teams based upon interest in a particular prototype. The prototype ideas included the following:


* Transitioning healthcare to a learning health system with or without technology


* Developing an open-space primary care clinic


* Getting technology to community health workers and community-based organizations


* Ensuring that every patient in America receives a tablet and communicates with any provider


* Bringing nurse leaders from all areas together to learn from each other


* Creating a system where the consumer is in the whole ecosystem (who is in the middle?)


* Activating a network of unpaid care givers to extend the healthcare team


* Developing a simple free translator for all EHRs mandated to all entities


* Creating an electronic multidisciplinary student health collaboration


* Developing a road map for remote patient monitoring to achieve population health




The summit increased the dialogue regarding care coordination and technology. Money and time were identified as barriers to having these prototypes developed and tested. Looking back, a second day to discuss such barriers would have been helpful, but was not planned. However, some of the members of Team IMPaCT have also built upon the results of the initial summit to further some of the prototype ideas. Since that time, other groups have also focused attention on using technology to improve care coordination. For example, there is a Big Data Science Committee looking at care coordination.


The group had hoped to move the innovative technology ideas related to care coordination forward through the summit and to bring interdisciplinary groups together. The discussion began, but more interdisciplinary discussion and resources (time and money) are needed to really make the necessary impact. Technology and informatics are changing rapidly. It is critical for nursing informatics leaders to ensure technology facilitates care transitions that help improve patient outcomes across all sectors of healthcare.




1. Berwick D, Hackbarth AD. Eliminating waste in U.S. healthcare. JAMA. 2012; 307(14): 1513-1516. doi:10.1001/jama.2012.362. [Context Link]


2. Patient Protection and Affordable Care Act. 2010. Accessed December 14, 2015. [Context Link]


3. Lamb G. Care Coordination: The Game Changer. How Nursing is Revolutionizing Quality Care. Silver Spring, MD:; 2014. [Context Link]


4. About ONC. Accessed December 14, 2015. [Context Link]


5. Furukawa MF, King J, Patel V, Hsiaso C, Adler-Milstein J, Jha AK. Despite substantial progress in EHR adoption, health information exchange and patient engagement. Health Aff. 2014; 33(9): 1672-1679. doi:10.1377/hlthaff.2014.0445. [Context Link]


6. Institute of Medicine (IOM) and Robert Wood Johnson Foundation. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: Institute of Medicine; 2010. Accessed December 14, 2015. [Context Link]


7. Liberating Structure: Including and Unleashing Everyone. Accessed December 14, 2015 [Context Link]