Describe two common models of care coordination and how nurses influence outcomes in each.

• A. Acute inpatient care and emergency response
• B. Case management (assessment, planning, coordination) and transitions of care programs (ensuring continuity)
• C. Telemedicine and home health only
• D. Fee-for-service billing heavy practice

Answer: (B)

Care coordination relies on structured roles that bridge care across settings. Two common models are case management, which starts with a comprehensive assessment and leads to a planned course of action with ongoing coordination of services across providers and settings, and transitions of care programs, which focus on ensuring continuity as patients move from one setting to another—such as from hospital to home—through deliberate discharge planning, medication reconciliation, patient and caregiver education, and timely follow-up.

Nurses influence outcomes in case management by performing thorough assessments, identifying barriers, developing and updating care plans, and coordinating with a multidisciplinary team to arrange needed services (home health, specialists, social supports) while monitoring progress. This holistic approach helps patients access appropriate resources, adhere to plans, and avoid unnecessary delays or duplications in care. In transitions of care programs, nurses lead discharge planning, ensure accurate medication lists and clear instructions, educate patients and families about what to expect at home, arrange post-discharge follow-up and appointments, and coordinate with primary care and community resources. These actions reduce post-dis discharge adverse events, lower readmission risk, improve medication safety and patient satisfaction, and support safer, smoother transitions. In both models, the nurse’s role centers on connecting information, people, and resources to keep the patient engaged and safe throughout the care journey.