Care Coordination Clinical Reasoning Model for Advanced Practice Nurses

In the current health care arena, practice has shifted to include systems thinking and value network analysis to determine priority patient health care issues that interface with interdependent health care provider roles and relationships. The major focus of current health care practice is interest in identification and achievement of patient health outcomes. To function effectively in this arena, nurses need outcome specification skills.  The role of case manager and care coordinator is becoming essential for meeting patient health care outcomes. Advance practice nurses such as nurse practitioners in these roles require additional clinical reasoning skill sets and ways of thinking to manage cases on a day to day basis if they are to practice to the full extent of their education (IOM, 2003).

 To expand the nursing process and include activities related to interprofessional collaboration, we propose a Care Coordination Clinical Reasoning framework that includes the OPT model of clinical reasoning and the CCCR systems model to thoroughly think and reason through patient and family cases to achieve outcomes across health care services. Clinical reasoning for case management includes care coordination competencies to address essential patient and family needs. The core competencies suggested by the Institute of Medicine include providing patient-centered care, working in interdisciplinary teams, employing evidence-based practice, applying quality improvement, and using informatics (IOM, 2003). These competencies are embedded in the AACN (2011) essentials for advanced practice nurse education and therefore important to the care coordination model we propose. These essential care coordination needs are; conducting a needs assessment, initiating medical care services and testing, evaluating capacity, resources and skills, developing an individualized plan of care, coaching and educating the patient and family, monitoring plan of care and safety, promoting self-management, and team collaboration.

Introduction to the Care Coordination Clinical Reasoning (CCCR) systems model web shows the essential care coordination practice issues and organizes thinking to focus on the priority needs within health care systems. The CCCR systems model then describes the care coordination practice issues and determines interventions, outcomes and the values for each essential need. This process involves individual-systems thinking, team-systems thinking and organizational-systems thinking to thoroughly and efficiently manage all aspects of patient and family cases.