Someone once said that, unlike many other occupations, nurses are nurses wherever they might be and whatever they might be doing — at the ballpark, out with their spouse, at the supermarket. Nurses always seem to be on the lookout for opportunities to help others and rarely shy away from any emergency that might come their way.

Heeding the call

For me, nursing is more than a job: it’s a privilege. It’s a hard, sad, tiring, funny, heartwarming, humbling profession that affords me the opportunity to assist others in the transitions of life, from birth to death.

I didn’t always want to be a nurse. I was one of those kids always bringing home injured stray animals. As I got older, that need led me to community volunteer work. In my early 20s, I realized I still had that yearning to serve, and that’s when I became an RN.

I can now look back on a rich career spanning 25 years of work in the hospital setting, as a manager in ambulatory care and as an educator. These experiences have provided me a holistic view of patients and their needs, as well as the needs of health care professionals who serve these patients.

A new, necessary certification

I know that, today, these needs have changed. People are living longer, however, many are living with multiple chronic diseases. According to the Centers for Disease Control and Prevention, one in four Americans live with more than one chronic illness, and that number rises to one in three for those over age 65.

Managing chronic illness is an expensive endeavor. Some estimates place the costs at 80 percent of all health care dollars spent in the United States.

The good news is that nurses, particularly in the ambulatory care setting, are uniquely qualified to work with patients, providers and people in the community to promote wellness. This, in turn, reduces costs.

…nurses, particularly in the ambulatory care setting, are uniquely qualified to work with patients, providers and people in the community to promote wellness.”

More good news: since 2015, nurses engaged in this kind of work can validate their competence and expertise by getting board certified. The credential is Certified in Care Coordination and Transition Management (CCCTM). Nurses with this certification are out there today, leading positive change.

A test case

Here is a case that demonstrates the CCCTM nurse’s impact. Mrs. B., 74, has diabetes, heart failure and is obese. She was discharged from the hospital following her third diabetic crisis in ten months. Each admission also involved a flare up of her heart condition. Diabetes and heart disease are among the priciest in terms of hospital readmissions, at $251 million and $1.7 billion dollars, respectively.

The CCCTM nurse caring for Mrs. B. educated her about monitoring her diabetes at home and about her medications in a way she could understand. This nurse also bridged the communication gaps that existed between the patient, the heart doctor and the diabetes doctor. Thanks to the nurse’s interventions and follow-up, Mrs. B. went ten months without requiring another hospitalization.

Synchronized healthcare

Mrs. B.’s case demonstrates the wave of the future and what effective care coordination can do for patients, facilities and the entire health care industry. It’s been one of the hottest topics in health care today, as leaders realized the consequences of patients falling through the cracks in the healthcare system due to the lack of coordinated care.

As the health care professional who spends the most time with patients, nurses are highly qualified to lead an interdisciplinary team. We have the skills, knowledge and training. And as CCCTM and care coordination continue to evolve, patients will no longer get lost in the system. Everyone will win.

And the rewards for CCCTM nurses like myself? The success of care coordination fulfills our collective sense of altruism and drive to serve the greater good, giving us all hope that we’ve found a better way.