The care continuum is a map of the places patients receive care — and the spaces between those places where coordination breaks down. NURS6612 takes students through each point on that continuum, examining what care coordination looks like, what can go wrong, and what MSN-prepared nurses can do to improve the patient experience as care crosses from hospital to post-acute, from specialist to primary care, and from the healthcare system to the community.
Care coordination at each point on the continuum
| Setting | Care Coordination Focus | Key Risks Without Coordination |
|---|---|---|
| Inpatient hospital | Discharge planning, interdisciplinary rounds, post-acute placement, medication reconciliation at admission | Inappropriate discharge, avoidable readmission, medication errors at transition |
| Hospital-to-home transition | Transitional care management, 48-hour follow-up calls, medication reconciliation, patient education, primary care appointment within 7 days | 30-day readmission — the highest-risk period; 1 in 5 Medicare patients readmitted within 30 days |
| Skilled nursing/rehab facility | Rehab goal coordination, care planning, family communication, return-to-community planning | Prolonged institutionalization, functional decline, hospital readmission from SNF |
| Home health | In-home assessment, medication management, wound care, functional status monitoring, caregiver support | Medication non-adherence, undetected deterioration, caregiver burnout |
| Primary care / PCMH | Chronic disease management, care team coordination, specialist referral management, care gap closure | Fragmented chronic disease management, missed preventive care, unmanaged comorbidities |
| Community/social services | Social determinants of health assessment, referral to food/housing/transportation programs, community health worker integration | Social needs unmet, medication access barriers, isolation worsening chronic disease |
Key topics in NURS6612
- Hospital discharge planning: CMS Conditions of Participation requirements, interdisciplinary discharge planning team, patient and family involvement, post-acute level of care determination
- Transitional care: the 30-day readmission window, TCM billing codes (99495, 99496), evidence-based transitional care interventions, medication reconciliation methods (Best Possible Medication History)
- Post-acute care settings: SNF, inpatient rehabilitation, LTACH, home health — understanding each setting's capabilities and limitations for care coordination planning
- Patient-centered medical home (PCMH): NCQA PCMH recognition standards, the care team model, care coordination within primary care, registry-based population management
- Accountable Care Organizations (ACOs): care coordination as ACO infrastructure, attribution, shared savings, total cost of care management
- Integrated care: behavioral health integration in primary care, co-location models, IMPACT depression care management, collaborative care teams
- Technology tools: care management software, electronic care plans, HIE for continuity, telehealth for care coordination follow-up, remote patient monitoring
- Interprofessional collaboration: hospitalists, primary care physicians, specialists, social workers, pharmacists, physical therapists — coordination across disciplines
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The hospital-to-home transition: highest risk on the continuum
- Scale of the problem: Medicare data show 1 in 5 Medicare patients is readmitted within 30 days; the NEJM analysis by Jencks et al. (2009) found 19.6% of Medicare discharges led to readmission within 30 days — 2.6 million readmissions per year, $17.4 billion in additional spending
- Root causes: Medication discrepancies (the Institute for Safe Medication Practices estimates 60% of patients have at least one medication discrepancy at discharge); inadequate discharge education; no primary care follow-up scheduled; unrecognized deterioration at home; social support failure
- Evidence-based solutions: Project RED (Re-Engineered Discharge): 11-component discharge intervention reducing readmissions 30%; BOOST (Better Outcomes by Optimizing Safe Transitions): Society of Hospital Medicine's toolkit; Care Transitions Intervention (Coleman): reduces 30-day readmission from 14.2% to 8.3% in RCT
- Financial pressure: HRRP penalty for excess readmissions — hospitals in FY2023 paid $521 million in total penalties; no hospital wants to be in the worst-performing quartile
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Frequently asked questions
Medication reconciliation is the process of comparing a patient's medication orders to all medications the patient has been taking, identifying and resolving any discrepancies. At care transitions — admission to the hospital, transfer between units, and discharge — medication reconciliation is where the most serious errors occur. The Joint Commission's National Patient Safety Goal on medication reconciliation requires hospitals to maintain and communicate an accurate medication list at transitions. The best practice is the Best Possible Medication History (BPMH): a comprehensive medication review using at least two sources (asking the patient AND reviewing pharmacy records AND reviewing prior medical records), conducted by a nurse or pharmacist. Discrepancies found include: medications taken at home that weren't ordered in the hospital (omissions), medications ordered in the hospital that weren't the patient's home regimen (commissions), dose or frequency differences. At discharge, a complete medication reconciliation ensures the patient leaves with an accurate medication list that matches what they should actually take at home. Studies show that 23–50% of patients have at least one medication discrepancy at hospital discharge without a formal reconciliation process — and about 11–13% of these are clinically significant.
The Patient-Centered Medical Home (PCMH) is a primary care model — defined by the NCQA and major primary care professional associations — that transforms primary care practices into care coordination hubs through 6 core concepts: patient-centered care (respect for patients' values and needs), comprehensive care (a team capable of meeting a broad range of patient health needs), coordinated care (coordination across the healthcare system and community), accessible care (shorter wait times, after-hours access, 24/7 telephone access), quality and safety (evidence-based medicine, quality improvement), and care team coordination (clear roles, team-based care, care manager role). NCQA awards PCMH recognition in three levels based on compliance with standards in the 6 core concepts. For care coordination nurses, the PCMH model is important because it explicitly designates care coordination as a primary care function — many PCMH practices employ registered nurses in dedicated care coordinator or care manager roles, responsible for managing high-risk patient panels, closing care gaps, and managing transitions from hospital back to primary care.