Achieving Care Coordination: Insight, Investigation, Introspection Required

Mary Naylor, PhD, RN, FAAN



Care coordination helps ensure a patient’s needs and preferences for care are understood, and that those needs and preferences are shared between providers, patients, and families as a patient moves from one healthcare setting to another. Care among many different providers must be well-coordinated to avoid waste, over-, under-, or misuse of prescribed medications, and conflicting plans of care. The coordination of care is both complex and challenging. Achieving it can be satisfying and exhilarating. Skills in assessing the system, identifying an action plan, and how it can all come together are identified.

Purpose/Goal: To provide nurses with skills in assessing the current care coordination system and in identifying an action plan.


1. Identify positive and negative characteristics of the practice environment that influence quality of care coordination.
2. Explain how patient discharge and home follow-up are influenced by appropriate care coordination.


Since 1990, Dr. Naylor has led a multidisciplinary program of research designed to improve the quality of care, decrease unnecessary hospitalizations and reduce health care costs for vulnerable, community-based elders. Dr. Naylor is the National Program Director for the Robert Wood Johnson Foundation sponsored Interdisciplinary Nursing Quality Research Initiative. She was elected to the National Academy of Sciences, Institute of Medicine in 2005. She also is a member of the RAND Health Board, the National Quality Forum Board of Directors and chairs the board of the Long Term Quality Alliance. She was recently appointed to the Medicare Payment Advisory Commission. BSN Villanova University, Villanova, PA Nursing 1971,MSN University of Pennsylvania, Philadelphia, PA Nursing 1973,PHD University of Pennsylvania, Philadelphia, PA Higher Education Administration 1982.

The planners and author(s) of this continuing nursing education activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.

Contact Hours: 1

Expiration Date: 12/21/2014


Member Price: $20.00
Non-Member Price: $30.00

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