About this Course

Welcome to the Primary care Improved Outcomes with Nurses in Evolving and Expanding Roles (PIONEER) Care Coordination course.  This course was developed as an extension to the HRSA-18-012 grant, led by Jo Robins, PhD. 

This training is for registered nurses in primary care and is primarily intended to benefit our clinical partners at the 5 practice sites that are part of the PIONEER project: The Center for Healthy Hearts (Links to an external site., Richmond Behavioral Health Authority (Links to an external site.), CrossOver (Links to an external site.), Hayes E. Willis Health Center (Links to an external site.) and VCU's Ambulatory Care Center (Links to an external site.). 

Course Description

This curriculum will provide registered nurses with foundational knowledge and skills in care coordination. Content focuses on defining the dimensions of care coordination, describing activities that are linked with care coordination competencies, and developing skills in caring for complex patients in primary care settings. This content aligns with the Care Coordination Transition Management Model as outlined by the American Academy of Ambulatory Care Nursing and the recommended care coordination action plan described by the American Nurses Association. Course activities are structured to establish knowledge, skills and confidence such that the registered nurse is able to work at the top of his or her licensure, with the intention of increasing job satisfaction and retention across one’s professional career.

Course Objectives

Participants will be able to:

1. Integrate care coordination and transition management strategies in primary care.
2. Prioritize care of patients who have the highest need for care coordination and transition management.
3. Design activities that will facilitate care coordination for patients with complex healthcare needs.
4. Recommend and implement nursing interventions that will facilitate high quality patient care outcomes.

Course Modules

The course is composed of a course orientation and 6 modules:

1. 1. 1. Professional Competence
      2. Care Transition Management
      3. Patient Engagement, Patient-Centered Planning, and Advocacy
      4. Quality Measurement and Health Information Technology
      5. Health Care Teamwork and Collaboration
      6. Support for Self-Management, Coaching, and Counseling of Patients

Additional Resources

Haas, S.A., Swan, B.A., Haynes, T.S. (Eds.) (2014). Care coordination and transition management core curriculum. American Academy of ambulatory Care Nursing.

Lamb, G. & Newhouse, R. (2018). Care coordination: A blueprint for action for RNs. American Nurses Association.