Care Coordination

Care coordination is the deliberate connection of the client, clinical information, services, and follow-up plan so that care remains safe when responsibility changes. It is not simply arranging an appointment or completing a discharge form. A plan fails when information is lost, no one owns the next step, the service is unavailable, or the client cannot carry out what was planned. A discharge order is a destination, not a bridge. The bridge is the assessment of current risk, a workable plan, a clear handover, and confirmation that the next person or service has received and understood the information. Nurses coordinate care by communicating, collaborating, and consulting with the client and the health-care team. The client’s goals and circumstances are part of the clinical picture. Medication access, transportation, language, cognition, mobility, caregiver availability, housing, and the ability to obtain equipment can determine whether a medically reasonable plan is safe in practice. In Ontario, Ontario Health Teams and Primary Care Networks provide integrated structures through which nurses may participate in care planning and navigation across services. These structures can connect primary care,...