Care coordination succeeds or fails at the level of specific, repeatable processes — who calls the patient after discharge, how a care plan gets shared across providers, what triggers an escalation. NURS6622 teaches those operational details.
Care coordination team roles and structure
NURS6622 covers the specific roles within a care coordination team — RN care coordinators, social workers, community health workers, and pharmacists — and how their scopes complement rather than duplicate each other. Students study role clarity as a critical success factor: care coordination programs frequently fail not from lack of resources, but from unclear division of responsibility leading to either duplicated effort or, worse, gaps where no one owns a critical task.
Care transitions and coordination process design
The course focuses heavily on care transitions — the highest-risk points in a patient's care journey, particularly hospital discharge — and evidence-based transition models like the Care Transitions Intervention and Project RED (Re-Engineered Discharge), which structure specific, timed processes (discharge medication reconciliation, follow-up appointment scheduling, post-discharge phone calls) to reduce readmission risk.
Key topics in NURS6622
- Care coordination team roles: RN coordinators, social workers, community health workers, pharmacists
- Avoiding role duplication and coverage gaps through clear scope definition
- Evidence-based care transition models: Care Transitions Intervention, Project RED
- Discharge medication reconciliation and post-discharge follow-up processes
- Designing escalation triggers and protocols for at-risk patients
- Cross-setting communication processes: hospital to primary care to home health handoffs
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Worked example: a structured hospital discharge transition process
- Day of discharge: RN conducts formal medication reconciliation, comparing home medications against hospital-prescribed changes
- Day of discharge: Follow-up primary care appointment is scheduled before the patient leaves the building, not left to the patient to arrange
- 48 hours post-discharge: A structured phone call checks for medication understanding, new or worsening symptoms, and barriers to the scheduled follow-up
- 7 days post-discharge: If the patient is high-risk, a second check-in call or home visit occurs before the readmission window closes
- Lesson: Reducing readmissions requires specific, timed, assigned processes — not a general instruction to "coordinate care better"
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Care coordination process design and care transitions assignments.
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Frequently asked questions
Care coordination inherently involves multiple professionals with overlapping potential responsibilities — an RN care coordinator, a social worker, and a community health worker might all plausibly be positioned to address a patient's transportation barrier to a follow-up appointment, for example. Without explicit, well-communicated role definitions, this overlap frequently produces one of two failure modes: duplicated effort, where multiple team members independently attempt to address the same issue (wasting scarce coordination time), or coverage gaps, where each team member assumes someone else is handling a specific need and it falls through entirely. NURS6622 teaches that well-designed care coordination programs invest significant upfront effort in explicit role and scope definition — documenting exactly which team member owns which type of task and when handoffs between roles should occur — because this structural clarity, not simply having more staff, is often the deciding factor between a care coordination program that functions smoothly and one that generates confusion and gaps despite adequate staffing.
Research consistently identifies the period immediately following hospital discharge as one of the highest-risk windows in a patient's care journey — patients are often still recovering, may not fully understand medication changes made during hospitalization, may lack a scheduled follow-up appointment, and are transitioning from a highly monitored environment back to managing their own care with much less support, all of which contribute to the well-documented pattern of preventable early readmissions. NURS6622 teaches evidence-based transition models like Project RED and the Care Transitions Intervention specifically because they target this exact window with structured, timed interventions — formal medication reconciliation before discharge, a scheduled follow-up appointment set before the patient leaves, and a structured check-in call within the first 48-72 hours — designed to catch and address the specific problems (medication confusion, missed follow-up, unrecognized worsening symptoms) that most commonly drive early readmissions, rather than leaving the transition to informal, unstructured processes that are more likely to let these risks go unaddressed.