Care Coordination Training Curriculum

Program Elements

Coaching

Coaching using individualized methods including case discussions, care plan auditing, quality indicator reporting and competency-based milestone assessment will challenge and promote growth in each care coordinator.

Processes

Care coordination processes include:

• Patient identification
• Family introduction
• Family agree/decline enrollment
• Medical record review
• Family intake interview
• Patient/family strengths and needs
• Family supports
• Goal setting and action planning
• Vetting Plan of Care with clinician
• Sharing Plan of Care with family
• Sharing Plan of Care with others
• Family first month outcome
• Family follow up and outcomes
• School outreach
• Registry entries and updates
• Plan of Care reassessments
• Outreach to unreachable family
• Family disenrollment

Reporting

Quality Indicator Reporting is delivered monthly and based on care coordinator activity entry in their individual patient registry. Coaches and care coordinators collaborate on tests of change to improve their individual processes. Reporting includes:

• Rate of enrollment to full registry
• Regular family contact at minimum every 90 days
• Share Plan of Care distribution
• First month outcome completion
• Key outcome completions
• Shared Place of Care updated

Competencies

Care Coordination Competencies measure milestones in skill acquisition over time, across levels from novice, to advanced beginner, to competent, to proficient, to expert care coordinator.

Care coordinators are provided opportunities to self-assess and receives assessment and feedback from their individual coaches.

Competencies include:

• Interdisciplinary team
  • Verbal and written communication
  • Teamwork
  • Population health
  • Quality improvement
• Relationship-centered care
  • Patient-centered care
  • Cultivate self-advocacy
  • Health literacy and education
• Information management  
  • Medical summary
  • Evidence-based practice
  • Goal setting
• System complexity and context
  • Medical and social complexity
  • Community resources
  • Outcome achievement
• Personal and professional development
  • Ethics and empathy
  • Self care
  • Self direction
• Human complexity and context
  • Cultural diversity
  • Tiered coaching
  • Person and family support

Development of the IC4 nurse-specific competencies was informed by the work of:

• Camden Coalition in Complex Care Core Competencies
• American Academy of Ambulatory Care Nursing (AAACN) in Care Coordination and Transition Management Curriculum
• Boston Children’s Interprofessional Education in Care Coordination Curriculum

Tools

Fingertip tools delivered in up-to-date resource library to facilitate navigation of health systems and government and community services:

• Advocacy
• Ancillary services
• Cultural/language adaptations
• Developmental disabilities rehabilitation
• Education
• Employment/work
• Family support and advocacy (natural and formal)
• Health system navigation
• Insurance and financing
• Juvenile and criminal justice
• Legal
• Long term care
• HCBS/waivers
• Public safety
• Recreation and community resources
• Social services
• Transition to adulthood

List adapted from: Schor E. An Almost Complete List of Services Used by Families and CSHCN. Lucille Packard Foundation, April 3, 2019.

Community of Practice

The longitudinal Community of Practice continues opportunities for shared learning, synthesis and problem-solving. Each session welcomes participants to:

• Relationally engage through sharing of updates and/or successes
• Focus on brief training in a specific care coordination skill
• Participate in the case discussion to apply the content into real world actions