coordination models which have been operationalized within targeted populations that have
fiscally reduced healthcare costs in the USA. A context of future globalization application of
these emerging models will be discussed.
Background The USA healthcare is complicated and the need for care coordination across
systems and providers is essential to maintain quality of care. NPs are ideally positioned to act
as leaders and clinicians both within and beyond the health care organization to deliver patient
centric transitional care and care coordination models in the heart failure, geriatrics, palliative
care and mental health populations.
Evaluation From the available research evidence, several support structures and mechanisms
are identified as enablers for NPs to enact their leadership role in transitional care and care
2. Agency for Healthcare Research and Quality. (2015). Care coordination. Retrieved fromhttp://www.ahrq.gov/ professionals/ prevention-chroniccare/improve/coordination). Accessed on Sept 30th, 2017.
3. Anderson GF, & Squires DA. (2010). Measuring the USA health care system: a crossnational comparison. Issue Brief: Commonwealth Fund, 90, 1-10.
4. Bauer JC. (2010).Nurse practitioners as an underutilized resource for health reform: evidence-based demonstrations of cost-effectiveness. Journal of American Academy of Nurse Practitioners, 22(4), 228-231.
5. Berwick D, Nolan T & Whittington J. (2008). The Triple Aim: care, cost, and quality. Health Affairs, 27(3), 759-769.
6. Campbell C, Craig J, Eggert J, & BaileyDorton C. (2010). Implementing and measuring the impact of patient navigation at a comprehensive community cancer center. Oncology Nursing Forum, 37(1), 61–68. doi:10.1188/10.ONF.61-68.
7. Coleman EA. (2003). Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 2003; 51(4): 549-555.
8. Deitrick LM, Rockwell EH, Gratz N, Davidson C, Lukas L, & Stevens D, et al. (2011). Delivering specialized palliative care in the community: a new role for nurse practitioners. Advance Nursing Science, 34(4):E23-36. doi: 10.1097/ANS.0b013e318235834f. PMID: 22067236.
9. Donald F, Kilpatrick K, Reid K, Carter N, Bryant-Lukosius D, & MartinMisener R, et al. (2015) Hospital to community transitional care by nurse practitioners: a systematic review of cost effectiveness. International Journal of Nursing Studies, 52(1), 436–451., Dubree M, Jones P, Kapu A, & Parmley CL. (2015). APRN Practice: Challenges, Empowerment, and Outcomes Nurse Leader. Retrieved from www.nurseleader.com, accessed September 20th, 2017.
10. Enguidanos S, Gibbs N, & Jamison P. (2012). From hospital to home: a brief nurse practitioner intervention for vulnerable older adults. Journal of Gerontology Nursing, 38(3):40-50. doi: 10.3928/00989134-20120116-01.
11. Evercare. (2006). Long term care reform: Integrated long term care. Retrieved from http://aspe.hhs.gov/ medicaid/may/Dr.JohnMach, accessed September 12th, 2017.
12. Feistritzer NR & Jones PO. (2014). A proof-of-concert Implementation of a unit-based advanced practice registered nurse (APRN) Rolestructural empowerment, role clarity and team effectiveness, Nursing Clinics of North America, 49(1),1-13.
13. Institute of Medicine. (2013). Delivering high-quality cancer care: Charting a new course for a system in crisis. Retrieved from http://iom. nationalacademies.org/reports/2013/ delivering-high -quality-cancer-carecharting-a-new -course-for-asystemin-crisis.aspx, accessed September 12th, 2017.
14. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.
15. International Council of Nurses. (2009) Fact Sheet: Nurse Practitioners/ Advanced Practice Nurse: Definition and Characteristics. Nursing Matters. Retrieved from http://www.icn. ch/images /stories/documents/ publications/fact_sheets/1b_FSNP_ APN.pdf. Accessed 19 September 2017.
16. Johnson F. (2015). Systematic review of oncology nurse practitioner navigation metrics. Clinical Journal of Oncology Nursing, 19, 308–313. doi:10.1188/15 .CJON.308-313.
17. Johnson F. (2016). The Process of Oncology Nurse Practitioner Patient Navigation: A Pilot Study. Clinical Journal Oncology Nursing, 20(2), 207- 210. doi: 10.1188/16.CJON.207-
18. Kleinpell R, Scanlon A, Hibbert D, Ganz FA, East L, Fraser D, et al., (2014). Addressing issues impacting advanced nursing practice worldwide. The Online Journal of Issues in Nursing,
19(2), Manusript 5. doi: 10.3912/OJIN. Vol19No02Man05. 19. Lawrence D. & Kisely S. (2010). Inequalities in healthcare provision for people with severe mental illness. Journal of Psychopharmacology, 24(4), 61–68. doi: 10.1177/1359786810382058.
20. Martin-Misener R, Harbman P, Donald F, Reid K, Kilpatrick K, Carter N, et al. (2015) Cost-effectiveness of nurse practitioners in primary and specialised ambulatory care: systematic review. British Medical Journal Open, 5(6), e007167. doi: 10.1136/bmjopen2014-007167.
21. McCauley KM, Bixby MB, Naylor MD. (2006). Advanced practice nurse strategies to improve outcomes and reduce cost in elders with heart failure. Disease Management, 9(5):302-310.
22. National Chronic Care Consortium. (2007). Moving to better chronic care in Medicare: NCCC proposals for change. Retrieved from http://www.nccconline. org/pdf/Waterf rontforWeb.pdf. Accessed September 15th, 2017.
23. National Council of State Boards of Nursing APRN Advisory Committee. (2008).
24. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. Completed through the work of the APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Advisory Committee.
25. Naylor MD. (2012). Advancing high value transitional care: The central role of nursing and its leadership. Nursing Administration Quarterly, 36(2), 115- 126.
26. Naylor MD, Bowles K, McCauley K, Maccoy M, Maislin G, & Pauly M, et al. (2013). High-value transitional care: Translation of research into practice. Journal of Evaluation in Clinical Practice, 19(5), 727–733.
27. Naylor MD, Brooten DA, Campbell RI, Maislin G, McCauley KM, & Schwartz JS. (2004).
28. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatric Society, 52(5), 675-684.
29. Naylor MD & Kurtzman ET. (2010). The Role of Nurse Practitioners In Reinventing Primary Care. Health Affairs, 29(5), 893-899.
30. Newhouse RP, Stanik-Hutt J, White KM, Johantgen M, Bass EB, & Zangaro G, et al.(2011) Advanced practice nurse outcomes 1990–2008: a systematic review. Nursing Economics, 29(5), 230–250.
31. Owens D, Eby K, Burson S, Green M, McGoodwin W, & Isaac M. (2012). Primary palliative care clinic pilot project demonstrates benefits of a nurse practitioner-directed clinic providing primary and palliative care. Journal of American Academy of Nurse Practice, 24(1):52-8. doi: 10.1111/j.1745-7599.2011.00664
32. Patient Protection and Affordable Care Act of 2010. (2010). Public Law 111- 148.
33. Piatt E, Munetz M, & Ritter C. (2010). An examination of premature mortality among decedents with serious mental illness and those in the general population. Psychiatric Services, 61(7), 663–666.
34. Robinson K. (2010). Care Coordination: A Priority for Health Reform Policy. Politics, & Nursing Practice, 11(4), 266 –274.
35. Rosales AR, Byrne D, Burnham C, Watts L, Clifford K, & Zuckerman DS, et al. (2014).
36. Comprehensive survivorship care with cost and revenue analysis. Journal of Oncology Practice, 10(2), E81– E85. doi:10.1200/JOP.2013.000945.
37. Sochalski J, Jaarsma T, Krumholz HM, Laramee A, McMurray JJ, & Naylor MD, et al. (2009). What works in chronic care management: The case of heart failure. Health Affairs, 28(1), 179-189.
38. Solomon P, Hanrahn NP, Hurford M, DeCesaris M, & Josey, L. (2014). Lessons Learned from Implementing a Pilot RCT of Transitional Care Model for Individuals with Serious Mental Illness. Archives of Psychiatric Nursing, 28(4), 250–255.
39. University of Washington. (2012). The global nursing leadership toolkit. Washington, DC: Center for Health Science Interprofessional Education, Research and Practice. Retrieved from http://collaborate. uw.edu/educators-toolkit/globalnursingleadershiptoolkit.html-0. Accessed September 25th, 2017.
40. U.S. Department of Health and Human Services. (2011). National Institute of Aging, National Institutes of Health & World Health Organization. Global Health and Aging. NIH Publication no. 11-7737.
41. Woltmann E, Grogan-Kaylor A, Perron B, Georges H, Kilbourne A & Bauer M. (2012). Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: Systematic review and meta-analysis. American Journal of Psychiatry, 169(8), 790–804.