Anne T. Jessie, DNP, RN
President-elect, The American Academy of Ambulatory Care Nursing
The American Academy of Ambulatory Care Nursing (AAACN) is an organization dedicated to advocating for ambulatory care nurses and offering opportunities for further education and leadership. Their education program for care coordination and transition management (CCTM) was started to help repair some of the gaps in America’s healthcare system.
“It’s well-recognized that healthcare in America is currently very fragmented,” said Anne T. Jessie, AAACN president-elect. “Patients receive care from a variety of physicians and nurse practitioners, primary care physicians, specialists such as cardiologists, endocrinologists, etc., and they receive that care in multiple locations — hospitals, clinics, doctors’ offices, urgent care, emergency departments, and skilled nursing facilities. Because of that wide variability, nurses, doctors, and hospital systems don’t always have the entire medical history for an individual patient or key information that’s needed to provide comprehensive and informed medical care.”
Slipping through the cracks
For patients treated by specialists for acute and chronic diseases, vital information can go uncommunicated to the patient’s other doctors or nurses.
“That lack of communication could cause medication errors, hospitalizations, unnecessary treatments, medications, and tests, which could lead to poor patient outcomes, and sometimes even death,” Jessie said.
AAACN developed their CCTM program to educate nurses with varying levels of experience to specifically coordinate care between multiple care facilities and reduce the errors in communication.
“This program really cares for patients in multiple care settings,” Jessie said. “Nurses in this role have broad and deep tools and skill sets to coordinate the care for any transition from one care setting to another so they’re safer and more effective.”
On the ground
“Here’s an example of the value of a CCTM nurse that I heard from a colleague,” Jessie continued. “A newly diagnosed male patient with diabetes was taught how to use an Insulin pen when he was in the hospital. However, this patient kept getting readmitted for high blood sugars and no one could figure out why.”
The CCTM nurse said the patient could describe how to use the pen and provided details of his diet, Jessie said. After additional patient questioning, the CCTM nurse finally realized that the patient wasn’t taking the tip off the Insulin pen when injecting himself.
“It was the CCTM nurse, who had the time, patience, and knowledge to drill down and figure it out,” Jessie said. “With a hectic and complicated healthcare system, cases like these don’t always get resolved quickly, and patients often get lost in a maze of providers. This is the value of having a nurse in a CCTM role: to avoid errors, communication gaps, and readmissions before patients suffer and healthcare costs go up needlessly.”
A personal touch
Jessie said that the personal element is also what attracts many nurses to ambulatory care and care coordination.
“Nurses are educated to treat the whole person — the physical, the mental, and the social well-being of each individual,” Jessie said. “They are translators. They take the information from other colleagues on the healthcare team, apply their critical thinking skills, and find solutions individualized to each patient.”
As well as providing a vital service to America’s healthcare system, CCTM nurses benefit from the relationships they build with patients.