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Home Healthc Nurse. 2014 Sep;32(8):470-5. doi: 10.1097/NHH.0000000000000126.

Care coordination in long-term home- and community-based care.

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  • 1Barbara Johansson, BSN, RN, CCM, CPUM, is a Commissioner, Commission for Case Manager Certification, Mount Laurel, New Jersey. She is also Staff Vice President for a national managed care organization. Jane Harkey, RN, MSW, CCM, is a Commissioner, Commission for Case Manager Certification, Mount Laurel, New Jersey. She operates a private geriatric care management practice.


This article examines the role of care coordination, when fulfilled by a professional board-certified case manager, in successful long-term home- and community-based care (HCBC). A facet of care coordination, as also discussed, is a robust assessment of the individual by the professional case manager, who devises and implements a comprehensive care plan to address the clinical, psychosocial, and environmental needs of the individual as part of a person-centered, evidenced-based approach. To be successful, long-term HCBC starts with a robust assessment of the individual by a professional board-certified case manager. The case manager uses specific tools that incorporate qualitative measurements to address factors such as medical/clinical needs, (e.g., diagnoses, chronic conditions, and/or health risks); mental/behavioral health (e.g., geriatric depression screening); medication/pharmacology (e.g., review and reconciliation of prescribed and over the counter medications and supplements) and the individual's ability to self-administer; home safety; and presence of a family/support system and their ability and willingness to provide care. Based on these findings, the case manager puts in place a comprehensive care plan, working with a well-coordinated multidisciplinary team, including informal supports, physicians, registered nurses, occupational therapists, pharmacists, social workers, nutritionists, and other allied health professionals. From the beginning, the rigor of care coordination is essential to the how successfully individuals and their families/support systems realize their goal of long-term HCBC.

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