NCLIP

Collaboration and Coordination of Care

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Collaboration and Coordination of Care

Key Points

  • Care coordination improves safety, continuity, and equity across psychiatric treatment transitions.
  • Case management models differ in intensity, role closeness, and scope of services.
  • Nurses are central care coordinators due to holistic assessment and longitudinal contact.
  • Telehealth expands access and supports cross-setting coordination for complex needs.

Pathophysiology

Fragmented care increases relapse, readmission, medication errors, and delayed intervention in psychiatric populations. Coordination reduces risk by aligning timing, communication, and resource access across providers and settings.

Addressing social determinants and transition gaps is a clinical safety intervention, not only an administrative function.

Classification

  • Brokerage model: Intermediary linkage between client and services.
  • Clinical model: Treating clinician also functions as case manager.
  • Intensive model: High-touch short-term support for severe complexity.
  • Strengths-based model: Recovery planning built on client capabilities and goals.

Nursing Assessment

NCLEX Focus

Prioritize transition risk, service-access barriers, and team communication gaps.

  • Assess acuity, complexity, and utilization patterns to match case-management intensity.
  • Assess social determinant barriers affecting continuity (housing, transport, finances, supports).
  • Assess treatment preferences, goals, and self-management capacity.
  • Assess interprofessional handoff quality and information continuity.
  • Assess telehealth readiness, digital access, and follow-up feasibility.

Nursing Interventions

  • Coordinate interdisciplinary plans with clear responsibilities and timelines.
  • Implement safe transition workflows from inpatient to community services.
  • Use strengths-based planning to increase client ownership and engagement.
  • Leverage telehealth and remote monitoring where clinically appropriate.
  • Advocate for equitable access to needed resources and follow-up services.

Transition Blind Spot

Discharge without coordinated follow-up and barrier mitigation markedly increases early relapse risk.

Pharmacology

Medication continuity is a core coordination outcome. Nursing case management ensures reconciliation, education, side-effect follow-up, and timely access to prescriptions across care settings.

Clinical Judgment Application

Clinical Scenario

A client with severe mental illness and unstable housing has repeated emergency visits after discharge despite medication changes.

Recognize Cues: High utilization with unmet social and coordination needs. Analyze Cues: Medication adjustments alone are insufficient without system integration. Prioritize Hypotheses: Priority is intensive coordinated support with rapid follow-up. Generate Solutions: Initiate intensive/strengths-based case management and telehealth check-ins. Take Action: Align team roles, secure community resources, and establish structured transition contacts. Evaluate Outcomes: Track readmission rate, appointment completion, and stability indicators.

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