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Nurse Care Coordinator Competencies and Milestones

In education, competencies are defined as the knowledge, skills, abilities, and behaviors that contribute to job performance, and milestones are the observable markers of performance along a developmental continuum.

To specifically focus the training and evaluation of nurses as care coordinators, IC4 sought and reviewed existing competencies as well as objectives in care coordination to inform the development of a framework. Existing resources included the Camden Coalition Complex Care Core Competencies, the American Academy of Ambulatory Care Nursing (AAACN) Care Coordination and Transition Management Curriculum and the Boston Children’s Interprofessional Education in Care Coordination Curriculum.

Six nurse care coordinator themes are currently used to anchor nineteen competencies. Each competency has specific language which describes milestones as performance expectations across the continuum from novice to advanced beginner to competent to proficient to expert. 

Theme Competencies
Interdisciplinary team (IDT)

1. Verbal/written communication (IDT1)
2. Teamwork (IDT2)
3. Population Health (IDT3)
4. Quality Improvement (IDT4)

Relationship-centered care (RCC)

5. Patient-centered care (RCC1)
6. Cultivate Self-Advocacy (RCC2)
7. Health literacy/ education (RCC3)

Information management (IM) 8. Medical summary (IM1)
9. Evidence-based practice (IM2)
10. Goal setting (IM3)
Systems complexity and context (SCC) 11. Medical and social complexity (SCC1)
12. Community resources (SCC2)
13. Outcome achievement (SCC3)
Personal and professional commitment (PPC) 14. Ethics & Empathy (PPC1)
15. Self-care (PPC2)
16. Self-direction (PPC3)
Human complexity and context (HCC) 17. Cultural diversity (HCC1)
18. Tiered coaching (HCC2)
19. Person/Family Support (HCC3)

Care coordinators themselves, coaches and primary care physician champions all contribute in the evaluation of competency and feedback discussions that are scheduled semi-annually. This activity assists to direct the tailoring of the educational process for each individual nurse’s needs and, when summarized across the care coordinator cohort, serves to reinforce and create areas for improvement in the full curriculum.

Examples of how an average nurse, who joins IC4 when new to care coordination, tends to progress along the following time continuum may be:

New care coordination (0-3 months) Mid-level care coordination (3-6 months) Advanced care coordination (6+ months)
Medical summary (IM1) Avoid errors in documentation, some gaps in information 
More complete information, editing duplications
Synthesized to a succinct and meaningful summary
Goal setting (IM3) Use standard goals, build trust by accomplishing easy tasks
Goals tailored to family, stretch towards longitudinal goals beyond basic health care
Motivate families to seize opportunities they may have missed
Tiered coaching (HCC2) Assign accountability based on issues of high risk with “I do” (as care coordinator) and of low risk with “you do” (as patient or family)
Assign variation in “I do, we do, you do” accountability based on patient or family ability
Grow patient or family abilities in self-advocacy so they can achieve their own goals as “you do”
Teamwork (IDT2) Relay accurate information to primary care team
Advocate more for the patient and family in tailoring care processes
Use succinct communication that cultivates patient/ family-centered chronic care by primary care team
Health literacy/education (RCC3) Verify patient or family comprehension of basic aspects of SPOC content, review as needed. Support self-management skills for typical families to be able to adjust their plan for illness flares, and urgent or emergent issues  
Provide effective, tailored, and targeted education for family success in self-management, across health literacy and/or cultural barriers
Quality Improvement (IDT4)
Receive feedback and apply suggestions for improvement
Receive feedback and create suggestions for own improvements
Seek feedback and engage team in plans for improvement