Care Coordination Certificate Course

ICAHN Member Critical Access Hospitals--Cost is $350

Flex pays for $150 scholarship for each participant.

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Course Syllabus and

In the 2015 report Policy Agenda for Nurse-Led Care Coordination, published jointly by the American Academy of Nursing and the American Nurses Association, it was noted that “Nurses have been and continue to be pivotal in the development and delivery of innovative care coordination practice models.”

As these innovative models are implemented, primary care health professionals, such as Nurses, primary care clinical staff and alike, must have the knowledge, skills, and abilities to provide effective care coordination.  The development of the knowledge, skills, and abilities must be based on research.

The education in this course is developed based on the “Seven Domains of Care Coordination in the Primary Care Setting” by Kristy Baker, APRN-CNP, a Duke-Johnson & Johnson Nurse Leadership Program FellowShe developed the list of domains utilizing an extensive literature search to gather evidence of the most important knowledge, skills, and abilities required for a care coordinator to be successful in the primary care setting.

This course is designed to provide health professionals, such as Nurses, primary care clinical staff and alike, to improve care coordination for patients with chronic conditions, behavioral health issues, as well as incorporating health promotion into their practice.

Course Dates:

Self-Paced – recommended timeline is approximately 16 weeks with access to the course for 12 months

Course Delivery Format:

The course is divided into ten (10) modules. Each module may take up to two (2) weeks. The development of care coordination skills occurs when knowledge and practice are combined. This Care Coordination Certificate Course will put knowledge into practice as participants are immersed in this interactive course. The education will be delivered in a virtual environment using a combination of pre-recorded didactic presentations, asynchronous discussion threads, and a virtual meeting space for a live monthly discussion with the instructors.

Course Outline:

Module 1 – Network Technology and Lean Overview

  • Power of Observation
  • Understanding Current State
  • Validation and buy-in Techniques

Module 2 – Population Health Management

  • Seven Domains of Care Coordination in the Primary Care Setting
  • American Demographics
  • Population Health Model

Module 3 – Comprehensive Assessment and Care Planning

  • Nursing Process
  • Patient Centered Care
  • Motivational Interviewing

Module 4 – Interpersonal Communication

  • Relationships and Trust
  • Team Based Care
  • Personality and Biases

Module 5 – Education and Coaching

  • Learning Theories
  • Learning Readiness
  • Learning Styles
  • Coaching Techniques

Module 6 – Health Insurance and Benefits

  • Medicare Basics
  • Care Management Services
    • Chronic Care Management (CCM)
    • Behavioral Health Integration (BHI)

Module 7 – Community Resources

  • Community resource requirement for CCM and BHI
  • How to identify community resources
  • How to invite community resources into the patient’s care

Module 8 – Health Promotion

  • Understanding the Annual Wellness Visit
  • How to incorporate health promotion models
  • Developing the Preventative Plan of care

Module 9 – Advance Care Planning

  • Understanding the integration of advance care planning in wellness
  • How to talk to patients about end-of-life planning
  • Developing the advanced care plan

Module 10 – Research and Evaluation

  • Understanding research
  • How to identify sources
  • Who are your potential partners?

Course Objectives:

At the completion of this course, the participant will be able to:

  1. Understand the basic elements of using a Lean Methodology for process change
  2. Explain the importance trends in the American population
  3. Discuss the population health models across the lifespan
  4. Develop patient centered goals for effective self-management
  5. Understand the elements required for developing long term relationships
  6. Evaluate learning readiness
  7. Identify learning styles
  8. Understand the progression of Medicare benefits
  9. Differentiate between team based, incident to, and provider services
  10. Identify appropriate community resources to incorporate into patients’ care plan
  11. Conduct an annual wellness visit
  12. Assist a patient with advance care planning
  13. Analyze research to incorporate into practice

Continuing Education Credit Calculations:

HealthTech Management Services D/B/A HealthTechS3 is a Provider approved by the California Board of Registered Nursing. Provider Number CEP8769 for 20 contact hours. Participant must complete all course work – no partial credit will be given. A certificate of completion will be provided by HealthTechS3 within 30 days of successful completion of the course.