Page 18 - MMP-N-NJ CCN 21st Century School Nurse Leadership Book

Key Principle: Care Coordination

Definition: Care coordination is a “deliberate organization of patient care activities between
two or more participants...to facilitate” the delivery of care (ANA, 2012, p.1). In addition to
case management and care transition, the broad principle of Care Coordination incorporates
many of the daily tasks school nurses perform to care for students and includes the
practice components of student-centered care, direct care, chronic disease management,
collaborative communication, motivational interviewing/counseling, nursing delegation and
student care plans.

PRACTICE COMPONENTS DEFINITION*

A process in which the school nurse identifies children
who are not achieving their optimal level of health or
academic success because they have a chronic illness
that is limiting their potential. It is based on a thorough
assessment by the school nurse and involves activities
that not only help the child deal with problems but
CASE MANAGEMENT also prevent and reduce their occurrence. Case
management includes direct nursing care for the child
and coordination and communication with parents,
teachers, and other care providers. Interventions are
goal oriented based on the specific needs of the child
and evaluated based on their impact on the child
(Engelke & Swanson, 2014).

School nurses engage in chronic disease management
CHRONIC DISEASE activities to provide for the best health, academic, and
MANAGEMENT quality-of life outcomes possible, with emphasis on
efficient care and student education leading to self-
management.

School nurses must communicate effectively to
coordinate care. Collaborative communication is clear,
cooperative communication used by school nurses
COLLABORATIVE to enhance collaboration with other members of the
COMMUNICATION school and community health team (e.g., the medical
home, health care provider, family, specialists, other
community organizations) to meet the health care
needs and goals of students (NASN, 2016a).

Care coordination provides for the direct care needs of
the student. The specific care that nurses and others
DIRECT CARE provide to students includes routine treatments,
medication administration, and addressing acute/
urgent needs.

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