Collaboration and Care Coordination
Collaboration and Care Coordination
This domain asks who needs to be involved and how information moves across settings. Know structured handoff tools such as SBAR and I-PASS, medication reconciliation, discharge planning that begins at admission, case management and utilization review, and the distinct roles of physical therapy, occupational therapy, speech-language pathology, social work, dietitian, pharmacy, respiratory therapy, and home health. The patient and family are team members, not recipients of decisions made about them; shared decision-making and cultural humility guide the plan.
Traps: trying to solve a social or financial problem alone instead of referring to social work or case management; waiting until discharge day to plan; excluding the patient or caregiver from goals; giving an incomplete handoff that omits allergies, code status, or pending results; and failing to reconcile medications at transitions, a leading cause of harm. Items also test conflict resolution among disciplines, where the nurse should address the issue directly and use appropriate escalation rather than avoid or overreport.
Rule of thumb: match the need to the right team member and start early. Example: an older adult admitted with a hip fracture lives alone in a second-floor apartment and wants to go home. The nurse starts planning on admission, requests physical and occupational therapy for mobility and self-care assessment, involves social work and case management for home safety, equipment, caregiver support, and funding questions, and completes medication reconciliation before transfer. The patient's preferences anchor the plan; the team supplies the expertise.