Unfolding Case Study Exemplifying Care Coordination with Advance Practice Nursing

The development, progression and evolution of the nursing process which begins with a foundation for patient problem management also parallels with dynamic thinking processes.  The third generation of nursing process or the Outcome-Present State – Test (OPT) emphasized clinical reasoning that was reflective, creative and outcome specific given a client’s story.  However, healthcare practice has yet shifted again to a focus on care coordination, systems thinking, value network and analysis to determine priority patient healthcare issues that interface with interdependent health care provider roles and relationships.

The authors propose a Care Coordination Clinical Reasoning model that includes structure, content and process to guide the novice practitioner through individual-systems thinking, team-systems thinking and organizational-systems thinking. The Care Coordination Clinical Reasoning (CCCR) systems model web shows essential care coordination practice issues and organizes thinking to focus on the priority needs within health care systems.  This framework utilizes standardized languages that are used to communicate between and among interprofessional health care providers.  For example, the Care coordination reasoning web organizes thinking to focus on priority health problems associated with ICD-9/ICD-10 medical diagnosis codes and aligns these with domains of nursing diagnoses.

The purpose of this presentation is to display an example of an unfolding case study commonly seen by nurse practitioner students in the primary care office setting.  This case study will show how the nurse practitioner uses the nursing process to assess, develop, implement, and evaluate an individualized plan of care with management and coordination across health care contexts.  A new care coordination clinical reasoning systems model will show the use of team and organizational-systems thinking to achieve health outcomes.  The participants will be engaged in an actual case development with the model worksheets for practice with care coordination essentials. The target audience of this presentation is graduate nurse clinical educators who teach advanced practice nursing students with a care coordination model.