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Care Coordination Training Curriculum

The IC4 coaching program accelerates the acquisition of competency for nurses in their roles as care coordinators. It focuses on the development of real world, point-of care skills to empower the delivery of comprehensive, family-centered, and targeted supports for patients and families.

The curriculum includes three phases: orientation, high intensity didactics and coaching and a longitudinal learning collaborative with ongoing coaching at a less intense volume.

triangle shows curriculum with orientation on the top, preliminary training in the middle, and learning collaborative on the bottom

Coaching Program

  • Orientation

    Duration: 1-2 Weeks Each nurse is onboarded as per the expectation in their own health system. In addition to local training, the university team provides ~ 6-8 hours of introduction to the IC4 processes. Orientation activities include:

    • Nurse onboarding processes
    • Primary care team introductions
    • Coaching introduction
    • Orientation didactics:
      • Principles of Care Coordination
      • Shared Plans of Care
      • Care Coordination Processes and Process Management
      • Resources, Coaching and the Collaborative
  • Preliminary Training

    Duration: Initial 6 Months (~3 hours per week) Each nurse joins a cohort of other new care coordinators to attend weekly virtual didactics, weekly one-on-one virtual coaching sessions with an experienced and trained care coordination coach and monthly statewide team meetings with the full community of care coordinators.

    1. Process and quality improvement coaching
    2. Case-based consultations
    3. Resource playbook distribution
    4. High intensity didactics with topics including:
      • A. Communication in Care Coordination
        • Motivational Interviewing: The basics
        • Navigating Sensitive Topics and Difficult Conversations
        • Trauma Informed Care
      • B. Population Health
        • Health Equity and Bias
        • Health Literacy Universal Design
        • Quadruple Aim –Quality, Cost, Family and Team Satisfaction
        • Social Determinants of Health – Beyond Medical Needs
      • C. Professional Development
        • Conflict management: De-escalation
        • Quality Improvement: In day-to-day work
        • Self-Care and Resilience: Boundaries and Ethics
      • D. Family Needs
        • Anticipating life transitions
        • Childcare, education, community services
        • Durable Medical Equipment and Supplies
        • Family and Social support
        • Goal setting: proactive, prioritized, lifecourse, strengths approach
        • Medicaid Basics
        • Medicaid HCBS waivers
        • Taking actions
  • Learning Collaborative

    Longitudinal ~3 hours per month Upon completion of the 6-month curriculum, each care coordinator joins the ongoing learning collaborative as a community of practice. Activities include:

    • Ad hoc and monthly coach case-based consultation
    • Quality improvement reporting and planning
    • Continuing education sessions
    • Resource updates

Care Coordination Quality Improvement Measurement

Quality improvement is a critical method used to propel each nurse care coordinator's acquisition of more effective processes. Data collection focuses on the key principles of the project, including frequent contact with enrolled families, regular updates of plans of care, effective sharing of plans of care, family satisfaction and primary care team satisfaction.

During the pilot, it was discovered that new nurse care coordinators were often familiar with types of quality measures used in primary care, without a functional background in the “why” of quality improvement principles. Therefore, an introduction of the basic methodology including the Plan, Do, Study, Act model for improvement was incorporated into the didactic series.  Coaching support is essential to help translate quality improvement theory into real world applications to encourage action for individual improvements.

Care coordinators receive monthly reports on quality indicators and related care coordination activity to identify and monitor program improvements at the individual and practice level.

a continuous circle shows arrows rotating between the words Plan, Do, Study and Act

Quality Indicators

  • Maintenance of a full registry of 100 patients.
  • Regular family contact at least every 90 days for at least 80% of their panel of 100 patients.
  • Shared Plan of Care updates at least every 6 months for at least 80% of their panel of 100 patients.
  • Average score of at least 30 (out of maximum 40) or 75% on chart audits of a sampling of 8-10 charts using a 20-item audit tool as scored by their coach.
  • Average distribution of at least 2 SPoCs to members of each patient's care neighborhood for at least 80% of their panel of 100 patients.

Family satisfaction surveys are collected semiannually from families who volunteer to participate.  Each practice receives an individual report, as well as shared summary for the whole project. Composite scores for care coordination, shared plans of care and medical home principles have demonstrated progressive improvement over the course of the project.

 

Contact Information

Contact us for more information about the Indiana Complex Care Coordination Collaborative.

Contact Us

Resources

Looking for patient care? Pediatric primary care can be reached at the site below.

Riley Primary Care