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  • Defining the role of the nurse care coordinator

    Author: Sharon Smith

Each year the Australian media covers the test cricket match played at the Sydney Cricket Ground where since 2008 the third day, or traditionally Ladies Day, has transformed the game into the Pink Test in support of the McGrath Foundation. After ten years of Pink Tests, the public are becoming familiar with the role of breast care nurses thanks to the McGrath Foundation which raises money specifically to fund the placement of breast care nurses in the community.

Acting as the patient’s clinical navigator to the world of healthcare, there are nurses working in many fields of care providing education about disease and self-management; behaviour change or health coaching principles to promote the uptake of recommended health maintenance practices. So-called nurse care coordinators can also conduct physician collaboration providing education to patients about how to communicate with healthcare team or communicating with members of the healthcare team on the patient’s behalf if it is required.

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While definitions of role responsibilities can differ between fields and facilities, there has been many studies done on measuring the effectiveness of specialist-trained nurses in transition care at levels of both patient satisfaction and service provider outcomes. A systematic review of this literature was carried out by the QUT School of Nursing in collaboration with the Queensland Government Office of the Chief Nursing and Midwifery Officer to develop key recommendations for these ‘nurse navigator’ roles.

The review, authored by Aaron Conway (QUT), Chris O’Donnell (Queensland Government) and Patsy Yates (QUT), covered 45 articles published after 2009, including participants receiving care in hospital and/or community settings in the United States, Australia and the United Kingdom. Conditions included in the review covered multiple comorbid conditions and were all commonly identified as ‘high risk’ conditions such as diabetes, dementia, terminal illness, children requiring special care, stroke recovery, COPD, bipolar disorder, disabled with functional impairments, requiring care in an aged care facility.

The patient-reported outcomes of this study indicated that patients with a variety of conditions receiving treatment from nurse care coordinators felt a reduction in their depressive symptoms, and better able to cope with pain and medication management. COPD patients in particular indicated lower symptom distress, such as reduced pain and improvement in sleep quality. There was a higher satisfaction reported by elderly and bipolar patients with the quality of care received by nurse care coordinators. Elderly patients with impaired ability to manage their medications reported a higher quality of life and ability to manage their medications – when provided more frequent nurse contact.


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The reporting of outcomes for health services was more reserved, noting the patients were already ‘high-risk’, suggesting concentrated care was already appropriate. The integration of the nurse care coordinator did not indicate an impact on hospitalisations or a reduction of the length of stay in readmissions or emergency department use however positive results were recorded in long-term outcomes. Treatment adherence was more likely to be carried out, especially in diabetic patients, and one randomly controlled trial reported a 29% reduction in home healthcare use for those receiving transition care.

The authors of the review note that while there are some excellent results in the smaller studies, such as certain programs producing cost savings of nearly $300 per month; reductions in length of hospital stay; and improvement in survival rates, the range of individual components of nurse care coordinator roles differed considerably across the studies that were examined. The findings of the review have been used to develop practice guidelines for the nurse care coordinator role in order to improve the effectiveness within the health services. The Queensland Office of the Chief Nursing and Midwifery Officer has developed a checklist to help conduct self-assessments and to support implementation for the Nurse Navigator role into health and hospital services. The full report can be read here.

Effective targeting of resources
Foster a system that facilitates effective targeting of navigation for high-risk patients (e.g. elderly, with chronic disease, poor health literacy, impaired ability to manage treatment, medications or self-care/self-management).

Establish confidence
Enable the participants to establish a sense of confidence in the navigator by providing regular and in-person contact over the course of the follow-up.

Promote integration
Promote the integration of the navigator role within the health care team. For example, ensure communication channels are available so that the navigator can facilitate collaborative development of treatment goals and corresponding care plans with the multidisciplinary care team efficiently.

Support self-management
Apply interventions to promote the uptake of health maintenance practices that are informed by principles from behaviour change theory (e.g., motivational interviewing).

Transition management
Provide transition management for patients being discharged from acute care. A number of evidence-based transition care models can be applied to practice, including Naylor’s Transition Care Model and Coleman’s Four Pillars for Care Transitions.


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Sharon Smith

Sharon Smith writes freelance articles as a medical, science and technology specialist. She is researching health journalism at Griffith University and lives mostly on Twitter @smsmithwriter (and would love to hear from you).