Coburn 1e

xviii

Contents

8 Care Coordination 146

Care Coordination in U.S. Healthcare 147 Care Continuum, Care Coordination, and Proliferation of Terms 148 Transitional Care 149 Scope and Standards of Practice for Care Coordination and Transition Management 151

Roles of Registered Nurses in Care Coordination 152 Roles of Registered Nurses During Care Transitions 154 Care Coordination and Care Transition Tools 156 The Role of Health Information Technology in Care Coordination 158 Summary 159

9 Telehealth and Virtual Care Nursing 163 Overview and Origins of Telehealth Nursing 163 Current Issues 166 Telehealth Nursing Practice 168 Nursing Process in Telehealth 169 Decision Support Tools 172 Telehealth Skills, Competencies, and Certification 174 Telehealth Nursing Practice Models 175 Remote Care Management 179 Future Challenges and Opportunities 180 Summary 181

Ambulatory Settings: Roles and Competencies 185

UNIT 4

10 Primary Care 187

History and Definitions 187 Workforce 189 Patient-Centered Medical Home and High-Functioning Primary Care 189 Team-Based Care 191 Registered Nurse Roles in Primary Care 195 Primary Care Registered Nurse Competencies 196 Behavioral Health in Primary Care 200 Population Health 201 Complex Care Management 202 Pediatric Primary Care 203 Insurance and Economic Issues 204 Health Information Technology, Data Tracking, and Clinical Decision Support Systems 205 Economic Impact of the Primary Care Registered Nurse Role 207 Summary 209