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Care Coordination in US health system Title: TBDWhat are the titles for care coordination? (Table 1) There are many titles for nurses who practice in a care coordination role such as (Patient) Care Coordinator(Patient) Care Facilitator(Nurse) Care Manager(Nurse) Case Manager?Case Management Administrator Discharge PlannerManaged Care Nurse Nurse Navigator(Advanced) Social Work Case ManagerTransitions ManagerTransitional Care ManagerTable 1. Titles for care coordination and designation1. Certified in Care Coordination and Transition Management (CCCTM)2. Nurse Case Management (RN‐BC)3. Certified Managed Care Nurse (CMCN)4. Accredited Case manager (ACM)5. Certified Case Manager (CCM)6. Case Management Administrators (CMA)7. Health Care Quality and Management and in the sub-specialty of case manager (CHCQM-CM)8. Health Care Quality and Management and in the sub-specialty of Transitions of Care (CHCQM-TOC)9. Certified Care Managers (CCM)10. Certified Social Work Case Manager (CSWCM)11. Certified Advanced Social Work Case Manager?(C-ASWCM)(Patient) Care Coordinator√(Patient) Care Facilitator(Nurse) Care Manager√√(Nurse) Case Manager?√√√√Case Management Administrator √Discharge PlannerManaged Care Nurse Nurse Navigator(Advanced) Social Work Case Manager√√Transitions Manager√Transitional Care Manager√Table 2. Titles of certifying bodies for care coordinationTitlesCredential/ Designation Title of examAccreditation Certifying Body/ web address Number of Members - (Patient) Care Coordinator- Transitions Manager1. Certified in Care Coordination and Transition Management (CCCTM)CCCTM certification examWill apply for ABSNC (Accreditation Board for Specialty Nursing Certification) when eligible. (200 certificants or 1 year)*Medical‐Surgical Nursing Certification Board (MSNCB)*American academic of Ambulatory Care Nursing (AAACN)* (Nurse) Case Manager?2. Nurse Case Management (RN‐BC)The ANCC Nursing Case Management board certification examinationABSNC (Accreditation Board for Specialty Nursing Certification) and The National Commission for Certifying Agencies? (NCCA)* American Nurses Credentialing Center (ANCC)* (Nurse) Care Manager3. Certified Managed Care Nurse (CMCN)Certification in managed care nursing?*American Association of Managed Care Nurses (AAMCN)* (Nurse) Case Manager?4. Accredited Case manager (ACM)ACMTM certification exam ?American Case Management Association (ACMA) * earned credential in 2017- (Nurse) Case Manager?5. Certified Case Manager (CCM)CCM? exam NCCA (National Commission for Certifying Agencies)Commission for Case Manager Certification (CCMC) * (Nurse) Case Manager?Administrators6. Case Management Administrators (CMA)Certification examination for Case Management Administrators ?The center for case management * ?*?- (Nurse) Case Manager?7. Health Care Quality and Management and in the sub-specialty of case manager (CHCQM-CM)Health Care Quality & Management (HCQM) Certification?*American Board of Quality Assurance and Utilization Review Physicians?(ABQAURP)’s Health Care Quality Management Board Certification (HCQM).?*CMSA* Transitional Care Manager8. Health Care Quality and Management and in the sub-specialty of Transitions of Care (CHCQM-TOC)Health Care Quality & Management (HCQM) Certification?*American Board of Quality Assurance and Utilization Review Physicians?(ABQAURP)’s Health Care Quality Management Board Certification (HCQM).?*CMSA* (Nurse) Care Manager9. Certified Care Managers (CCM)Certified Care Managers (CCM) exam ?*National Academy of Certified Care Managers (NACCM)* (Advanced) Social Work Case Manager10. Certified Social Work Case Manager (CSWCM)No exam: BSW experience required National Association of Social Workers (NASW)*National Association of Social Workers (NASW)* (Advanced) Social Work Case Manager11. Certified Advanced Social Work Case Manager?(C-ASWCM)No exam: MSW experience required National Association of Social Workers (NASW)National Association of Social Workers (NASW)* 3. Eligibility by certification body of care coordinationTitlesCredential/ Designation Audience Duration Practice Source- (Patient) Care Coordinator- Transitions Manager1. Certified in Care Coordination and Transition Management (CCCTM)RNs in a care coordination and transition management role5 yearsa. Minimum time in practice: 2 Yearsb. Type of practice: Clinical, management, or educationc. Practice hours: 2,000 Hours/3 years (Nurse) Case Manager?2. Nurse Case Management (RN‐BC)RNs in a case management role5 yearsa. Minimum time in practice: 2 Yearsb. Type of practice: Clinicalc. Practice hours: 2,000 Hours/3 years (Nurse) Care Manager3. Certified Managed Care Nurse (CMCN)RNs or a LPN in US, or a valid social worker license3yearsa. Minimum time in practice: 3 yearsb. Type of practice: ?c. Practice hours: ? (Nurse) Case Manager?4. Accredited Case manager (ACM)RNs, social workers4 yearsa. Minimum time in practice: 2 yearsb. Type of practice: case managerc. Practice hours: 2,080 hours/ 2 years (Nurse) Case Manager?5. Certified Case Manager (CCM)Any health or human services professionals including RNs in a case management role5 yearsa. Minimum time in practice: 2 Years or 1 year supervised or 1 year supervising / in past 5 yearsb. Type of practice: Clinical, managementc. Practice hours: 12 months full-time supervised by a CCM (Nurse) Case Manager?Administrators6. Case Management Administrators (CMA)Case manager, A-CCC, ACM, CRRN, CCM, CDMS, C-SWCM and C-ASWCM,RN5 yearsa. Minimum time in practice: 1 yearb. Type of practice: case management, case manager, case management administration, and a case manager c. Practice hours: 1, 3, 3, 5 each (Nurse) Case Manager?7. Health Care Quality and Management and in the sub-specialty of case manager (CHCQM-CM)1. Current Diplomate status with ABQAURP.?2. Current, non-restricted licensure and/or certification ?a. Minimum time in practice: 3 years b. Type of practice: must be devoted to each Sub-Specialty, which is an average of two hours per week over three years.c. Practice hours: 312 hours Transitional Care Manager8. Health Care Quality and Management and in the sub-specialty of Transitions of Care (CHCQM-TOC)1. Current Diplomate status with ABQAURP.?2. Current, non-restricted licensure and/or certification?a. Minimum time in practice: 3 years b. Type of practice: must be devoted to each Sub-Specialty, which is an average of two hours per week over three years.c. Practice hours: 312 hours (Nurse) Care Manager9. Certified Care Managers (CCM)at least 2 years of CM experience any degree in an unrelated field?a. Minimum time in practice: 1 yearsb. Type of practice: managementc. Practice hours: 1 year and 1.28 months of full time employment (Advanced) Social Work Case Manager10. Certified Social Work Case Manager (CSWCM)social workers?5 yearsa. Minimum time in practice: 2 yearsb. Type of practice: BSW level social work case managementc. Practice hours: 3,000 hours/ 2 years (Advanced) Social Work Case Manager11. Certified Advanced Social Work Case Manager?(C-ASWCM)Master’s social workers 5 yearsa. Minimum time in practice: 2 yearsb. Type of practice: post-MSW case managementc. Practice hours: 3,000 hours/ 2 Years 4. Comparing Core curriculumCredential/ DesignationCore curriculum# of curriculumsSource 1. Certified in Care Coordination and Transition Management (CCCTM)AdvocacyEducation and Engagement of Patients and FamiliesCoaching and Counseling of Patients and FamiliesPatient-Centered Care Planning Support for Self-ManagementNursing Process: Proxy for Monitoring and EvaluationTeamwork and CollaborationCross Setting Communications and Care TransitionsPopulation Health Management10Haas, S. A. (2014).?Care coordination and transition management core curriculum. American Academy of Ambulatory Care Nursing.2. Nurse Case Management (RN‐BC)collect information research/criteria resourcesdevelop plan of care aestablish patient-centered goals aimplement patient-centered goals a Evaluate patient-centered goals ameasure outcomes 3. Certified Managed Care Nurse (CMCN)Care, chronic condition, quality & utilization managementThe history of healthcare as it relates to the development of managed careManaged care products & reimbursementUsing information technology for managed careNegotiation skills for managed care nursesLegal and risk management issuesA nurse's role in ethical decision makingIntroduction to nursing informaticsNursing implications of managed care contractingConsumer advocacyAccreditation and provider profilingContinuous Quality ImprovementHealthcare reform & looking forwardManaged Care Nursing model & glossary of terms. Accredited Case manager (ACM)? the book (-) 5. Certified Case Manager (CCM)? The CCM? exam is practice-based, meaning all questions are based around knowledge that an experienced case manager should know and understand. As an exam candidate, you are not required to take any course or purchase any study materials.2-day CCM? certification worships. Case Management Administrators (CMA)I.??? Management, LeadershipCollaboration with Executive Team Human Resource Management Change Management II.?? Health care laws and regulationsCompliance, Laws, and Regulatory Organizations Legal Considerations for Patient Care Related to Case Management III. Development of a Continuum of CareService Gap Analysis Risk-based Contracting/Bundled Payments Assessment of At-Risk Populations Improving Population Health Programs of Care Accountable Care Organizations(ACOs) Functions of Emergency Department Case Management Medical Homes and Medical Specialty “Neighborhoods” Skilled Nursing Facilities—Short and Long-term Home Care and Hospice Outpatient Services for Physical and Mental Health Community Services and Resources Developing and Using Care Plans, Guidelines, and Paths to Manage Patients Across Continuum Skills Needed by Professionals in the Continuum Trends Toward Consumerism In-Patient Rehabilitation Facility(IRF)Long Term Acute Care Hospital (LTACH) Critical Access Hospital (CAH)IV.? Tools of clinical case management practiceCase Management-Related Software Information Technology Assessment and Intervention Tools V.?? Using data to create information, understanding, and improvementData that is Publically Available Payer Mix Data Quality Data Satisfaction Data Financial Data Physician Utilization Data/Practice Profiles and Feedback Methods Visual Data Displays Using Dashboards for Case Management Services Principles of Performance Improvement/Continuous Quality Improvement Predictive Modeling Health Plan Strategies . Health Care Quality and Management and in the sub-specialty of case manager (CHCQM-CM)Patient SafetyPhysician Advisor RolesTransitions of CareAccreditation OrganizationsInsurance and Managed CareWorkers CompensationCase ManagementClinical Resource ManagementCredentialing and PrivilegingQuality Improvement, Quality Management, and Quality AssuranceRisk ManagementRegulatory Environment. Health Care Quality and Management and in the sub-specialty of Transitions of Care (CHCQM-TOC)Patient SafetyPhysician Advisor RolesTransitions of CareAccreditation OrganizationsInsurance and Managed CareWorkers CompensationCase ManagementClinical Resource ManagementCredentialing and PrivilegingQuality Improvement, Quality Management, and Quality AssuranceRisk ManagementRegulatory Environment. Certified Care Managers (CCM)The care manager certification demonstrates competency in aging and disability issues community services and resources chronic disease management benefits and financing options legal and ethical concerns special needs and advocacyfamily support and conflict resolution . Certified Social Work Case Manager (CSWCM)Standard 1. Ethics and Values Standard 2. Qualifications Standard 3. Knowledge Standard 4. Cultural and Linguistic Competence Standard 5. Assessment Standard 6. Service Planning, Implementation, and MonitoringStandard 7. Advocacy and Leadership Standard 8. Interdisciplinary and Interorganizational CollaborationStandard 9. Practice Evaluation and ImprovementStandard 10. Record Keeping Standard 11. Workload Sustainability Standard 12. Professional Development and Competence. Certified Advanced Social Work Case Manager?(C-ASWCM)??Table 4.1. Summary competency of core curriculums with Care coordination 1. Certified in Care Coordination and Transition Management (CCCTM)2. Nurse Case Management (RN‐BC)3. Certified Managed Care Nurse (CMCN)Accredited Case manager (ACM): Order the book (-)Certified Case Manager (CCM): : emailCase Management Administrators (CMA)Transitions of Care Sub-Specialty CertificationCertified Care Managers (CCM)Certified Social Work Case Manager (CSWCM)The Certified Advanced Social Work Case Manager?(C-ASWCM): : emailTotal (n)Advocacy√√√3Education and engagement of patients and families√1Coaching and counseling of patients and families√Patient centered care planning√√a√√4Support for self-management√1Nursing process: proxy for monitoring and evaluation√Teamwork and collaboration√√√√4Cross setting communications √√3Care transitions√√2Population health management√Collect information √Research/criteria resources√Measure outcomes√Care, chronic condition, quality & utilization management√The history of healthcare√1Managed care products & reimbursement√Using information technology√1Negotiation skills for managed care nurses√Legal and risk management√√2ethical decision making√√2Introduction to nursing informatics√Nursing implications of managed care contracting√Accreditation and provider profiling√Quality Improvement√√2Healthcare reform & looking forward√Managed Care Nursing model √benefits and financing options √√3aging and disability√1Leadership√√2Assessment√√2Using data√√2Cultural and Linguistic Competence √1Professional Development and Competence√1ability to effect change √1Negotiation √1Total (n) 10314??6738?a. develop plan of care + establish patient centered goal + implement patient-centered goals + Evaluate patient-centered goals Table 5. Roles or responsibilities of care coordination Role / Responsibilities Source Certified in Care Coordination and Transition Management (CCCTM)discharge planning, telehealth, case management, utilization review, providing consultation, quality assurance, patient/family education, and interprofessional collaboration Case Management (RN‐BC)clinical processutilization review demand management care management quality management disease management appealsmedical claims reviewcare transitions Managed Care Nurse (CMCN)Accredited Case manager (ACM)Certified Case Manager (CCM)Case Management Administrators (CMA)Case finding Comprehensive assessment of client situation Evaluation and coordination of the plan of care Matching client resources to client needs Monitoring delivery of services Critical thinking, appropriate prioritization, and time management Measurement and evaluation of financial, clinical, functional, and satisfaction outcomes Accountability for financial, clinical, functional, and satisfaction outcomes Effective leadership displayed in the performance of current role Effective communication Evaluation of and response to the learning needs of clients, clinicians, and community of Care Sub-Specialty CertificationCertified Care Managers (CCM)ENGAGEMENT Outreach, working alliance, screening, consent (release) forms, initial intake, receiving referrals ASSESSMENT Needs (functional and/or psychosocial), strengths/ challenges/opportunities, biopsychosocial, comprehensive intake, sociocultural, resource/financial PLANNING Service, intervention, treatment, care, direction, rehabilitation, strategic, support, crisis prevention IMPLEMENTATION/COORDINATION Resource/service brokering, monitoring service delivery, service provision, project implementation, client support, crisis management ADVOCACY Working for systems improvement, promoting client well-being and/or client-functioning, liaison, and mediation REASSESSMENT/EVALUATION Monitoring, efficacy, effectiveness, appropriateness, efficiency, review/revise, plan, data collection and analysis DISENGAGEMENT Termination, transfer, discharge planning Social Work Case Manager (CSWCM)The Certified Advanced Social Work Case Manager?(C-ASWCM)6. Training Programs Programs Clinical Nursing Leaders (CNL) focused on: care coordination, transitions of care… (master’s degree) nursing specialists (master’s degree and DNP programs) Schools CertificateSchools program titles Eligibility WebsitesCreighton University certification on outcome management and care coordination leadershipRN Universitypopulation care coordinator program? UniversityCertificate in Health and Wellness Coachinghold a bachelor's degree or the equivalent? UniversityClinical case management/ care coordination Certificate program Bachelor’s degree in nursing or other health care/social service discipline from a nationally accredited college or university.A minimum of GPA of 3.0 on a 4.0 scale? Program in Case Management? University Certificate in Population-Based Care CoordinationCompletion of a bachelor's degree in nursing from a regionally accredited institution.Current registered nurse’s license in good standing.Cumulative GPA of 3.0 on a 4.0 scale in past academic work. of RochesterCare Manager Education Program? of Southern IndianaCase Management/Care Coordination Certificate ProgramEnglish-speaking nurses, social workers, and other healthcare professionals? Commonwealth University Care Coordination, Certificate in (Post-baccalaureate graduate certificate)? level Schools offered programs Eligibility WebsitesArizona State Universityonline bachelor of science in health care coordinationTop 25% in high school graduating class3.0 GPA in competency courses (4.0 = A)ACT 22 (24 nonresidents)*SAT Reasoning 1040 (1110 nonresidents)*’s level Schools offered programs EligibilityWebsitesAmerican Sentinel UniversityMSN Case ManagementRN licenseBachelor of science nursing degree with a minimum GPA of 2.0 UniversityMSN care coordination degree online? UniversityThe Master of Science in Health and Wellness CoachingProof of completion of a health related degree, credentialing, or health related coursework UniversityMSN Case Management online Degree Program? Names UniversityMaster of Science in Nursing (MSN)/Care Transition Management (CTM)? University of Integrative HealthMasters of Arts in Health and Wellness Coaching? Hall UniversityOnline M.S.N., Health Systems Administration with Case Management? Outline for care coordinationOption AIntroduction History of care coordination Definition of care coordination The importance of care coordination Gaps Aim Comparing and contrasting the characteristics of care coordination (titles, credential, exam, core curriculum, certifying body, eligibility, accreditation, certification duration, minimum time in practice, type of practice, minimum practice hours) Describe training programs for care coordination and transition management (CNL, CNS, Duke)MethodsWeb-based search/ literature review Finding Programs and Schools that offered certificate, BSN, master’s programs for care coordination Eligibility by certification body of care coordinationSummary competency of core curriculums with Care coordination Discussion Inform job description and hiring pattern/practice delivery What kinds of training are needed?Inform curriculum of nursing education related to care coordination Team-based principles Other projects Analysis of Survey on electronic care planning from AAACN Option C Comparing how hospitals use coordination of care delivery (role titles, preparation and job description) Methods: - Exclude specialty care coordinator - Some nursing degrees such as CNL, CNS in which their role included care coordination roles References (under construction)American Academy of Ambulatory Care Nursing. (2014). The role of the registered nurse in ambulatory care position statement.Camicia, M., Chamberlain, B., Finnie, R. R., Nalle, M., Lindeke, L. L., Lorenz, L., ... & Jones, T. (2013). The value of nursing care coordination: a white paper of the American Nurses Association.?Nursing Outlook,?61(6), 490-501.Craig, C., Eby, D., & Whittington, J. (2011).?Care coordination model: better care at lower cost for people with multiple health and social needs. Institute for Healthcare Improvement.Haas, S. A., & Swan, B. A. (2014). Developing the value proposition for registered nurse care coordination and transition management role in ambulatory care settings.?Nursing economic$,?32(2).Nutt, M., & Hungerford, C. (2010). Nurse care coordinators: definitions and scope of practice.?Contemporary nurse,?36(1-2), 71-81.Rosenberg, K. (2012). RN population care coordinators.?AJN The American Journal of Nursing,?112(5), 16.Moss, J. E., Flower, C. L., Houghton, L. M., Moss, D. L., Nielsen, D. A., & Taylor, D. M. (2002). A multidisciplinary Care Coordination Team improves emergency department discharge planning practice.?Medical Journal of Australia,?177(8), 435-439.Yates, P. (2004, November). Cancer care coordinators: realising the potential for improving the patient journey. In?Cancer Forum?(Vol. 28, No. 3, p. 128). The Cancer Council Australia.Joint Statement: The Role of the Nurse Leader in Care Coordination and Transition Management across the Health Care Continuum Management: Implications for Medical Practice, Health Policy, and Health Services Research Registered Nurse Residency White Paper – The Need for an Ambulatory Nurse Residency Program promise of care coordination transforming healthcare delivery information excluded from this manuscript 2. Disease specific care coordinators in Nursing (Specialty)Certified Cardiovascular Care Coordinator (C4) Nursing Navigator Coordinatorcertifying body: American Board for transplant certification (ABTC) has Certified Procurement Transplant Coordinators (CPTC):?Candidates must complete 12 months of work experience as a vascular organ procurement coordinator.Certified Clinical Transplant Coordinators (CCTC): Candidates must complete 12 months of clinical vascular organ coordinator?work experience.?Certified Clinical Transplant Nurse (CCTN): Candidates must complete 24 months' work experience as a registered nurse, including 12 months of direct involvement in the care of the solid organ transplant patient. For information on conversion of standard units to international units for the CCTN examination, visit?Jay Clinical Services? and?.Certified Transplant Preservationist (CTP): Candidates must complete 12 consecutive months of work experience in organ preservation (though organ preservation does not have to be the full time work responsibility).Evaluate compliance with standards: National Commission for Certifying agencies (NCCA)Click on the following links to learn more about the variety of accreditation programs offered by each institution:?ACHC?- Accreditation Commission for Health CareANCC?- American Nurses Credentialing CenterCARF?- Commission on Accreditation of Rehabilitation FacilitiesNCQA?- National Committee for Quality AssuranceURAC?- Utilization Review Accreditation CommissionThe Joint Commission ................
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