The Role of the Nurse Leader in Care Coordination and Transition Management across the Health Care Continuum

As health care’s rapid pace of change continues, it is imperative that new models of care incorporate a broad understanding of care coordination and transition management across the continuum. Nurses are well positioned to coordinate and deliver these services to patients.

Care coordination and transition management roles are needed to support achievement of the Triple Aim: improving quality of care to individuals, improving the health of communities and simultaneously reducing costs. Comprehensive strategies are needed to assure patients and families experience seamless care provided by interprofessional care teams across health care settings. Strong leadership is needed to strategically drive innovation and inspire transformative change in a complex health care environment. The role of the nurse leader is to advocate the value of nursing in care coordination and transition management.

The American Organization of Nurse Executives and the American Academy of Ambulatory Care Nursing collaborated to outline how nurse leaders in inpatient and post-acute/outpatient settings should approach their roles to enhance development of care coordination and transition management across the continuum of care.

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