Listen to patients using verbal and nonverbal cues to understand their needs and concerns.

Use simple, person-centered language when explaining procedures or plans of care.

Use open-ended questions to elicit patient values and preferences, documenting them accurately in the medical record.

Anticipate patients’ needs based on non-verbal cues and the clinical context, responding with appropriate emotional and clinical support.

Leverage communication skills to elicit verbal and nonverbal information to inform the plan of care.

Ensure patient preferences are consistently revisited and reflected in interdisciplinary team discussions.

2.1b Demonstrate compassionate care.

Demonstrate presence through eye contact, active listening, and appropriate verbal/nonverbal actions.

Identify individual preferences to begin incorporating them into actions and conversations.

Remain fully present even in high-stakes or emotionally charged situations.

Integrate individual patient preferences and emotional support into every interaction.

Engage with healthcare team members to create a seamless, person-centered care experience, respecting holistic needs.

2.1c Establish mutual respect with the individual and family.

Use clear, patient-centered language and encourage patients to ask questions and clarify misunderstandings.

Identify culture, values, beliefs, background, and developmental needs.

Seek input and affirmation from the patient and significant others.

Adjust communication approaches in real-time as needed, ensuring concerns from the patient and their significant others are addressed.

Integrate understanding of patients and significant others into actions and conversations.

Engage family members or other key support individuals in conversations to ensure understanding and two-way communication.

2.1e Foster caring relationships.

Engage with patients to explore questions and concerns, using open-ended questions to gain a comprehensive view of their situation.

Validate others' experiences and emotions in health care.

Build trust by maintaining eye contact and acknowledging concerns with appropriate verbal and non-verbal affirmations to demonstrate understanding and relatability in patient interactions.

Use patient concerns and situations to individualize holistic care.

Tailor interventions to respect the cultural, ethical, and spiritual preferences of patients and families.

2.2a Demonstrate relationship-centered care.

Use therapeutic communication strategies and demonstrate empathy when interacting with patients, families, and caregivers, ensuring clear and respectful communication.

Collaborate with patients and other healthcare team members to identify patient preferences, values, and cultural considerations without making assumptions.

Contribute to team discussions by sharing insights from patient interactions to support a holistic care approach.

Integrate patients’ cultural, emotional, and social needs into care plans.

Facilitate patient autonomy by involving them in decision-making and providing relevant resources to support informed choices.

Advocate for the patient’s needs and preferences within the care team, ensuring they are reflected in care decisions.

2.2b Consider individual beliefs, values, and personalized information in communications.

Acknowledge patients' beliefs, values, and cultural practices during care.

Incorporate patient preferences into communication.

Apply cultural humility and cultural competence in care discussions, fostering mutual understanding and respect.

Resolve potential misunderstandings with cultural humility, mitigating implicit biases.

2.2c Use a variety of communication modes appropriate for the context.

Identify standard communication methods to share and receive information effectively with patients and team members.

Adjust communication style based on the needs of patients.

Demonstrate respect and professionalism when communicating with diverse individuals.

Apply appropriate communication methods to share clear and comprehensive information tailored to diverse healthcare settings.

Customize communication approaches to align with the patient's needs to ensure understanding.

Demonstrate skills in interdisciplinary communication, fostering effective teamwork and mutual understanding.

2.2d Demonstrate the ability to conduct sensitive or difficult conversations.

Prepare for sensitive conversations by reviewing relevant patient information and considering cultural and emotional factors affecting the interaction.

Use empathetic language and demonstrate active listening, ensuring patients or families feel heard and understood.

Convey information clearly and respectfully, using simple language to discuss complex topics while ensuring comprehension.

Create an environment fostering trust, privacy, and emotional safety, ensuring patients and families feel comfortable expressing their thoughts and concerns.

Handle conversations involving conflicting perspectives or heightened emotions with professionalism and composure, focusing on the patient’s needs and goals.

Utilize reflection, validation, and de-escalation techniques to navigate sensitive or emotionally charged topics effectively.

2.2e Use evidence-based patient teaching materials, considering health literacy, vision, hearing, and cultural sensitivity.

Identify and select evidence-based education materials aligning with the patient’s health literacy levels and preferences.

Demonstrate cultural humility by selecting materials that are respectful and relevant to the patient’s cultural background and values.

Ensure understanding by asking open-ended questions and encouraging patients to repeat key information in their own words.

Tailor evidence-based teaching materials to meet individual patients' or families' specific educational needs, cultural context, and preferences.

Anticipate and address barriers to understanding using interpreters and/or culturally appropriate resources.

Identify and respond appropriately to verbal and non-verbal emotional expressions from patients, families, and team members.

Identify appropriate strategies to deliver bad news.

Demonstrate self-awareness and self-regulation while communicating.

Lead sensitive discussions confidently and tactfully, ensuring all parties feel respected and supported.

Use advanced communication strategies to communicate ideas.

Demonstrate accuracy and clarity in electronic and written documentation, ensuring information is accessible and actionable for interdisciplinary teams.

Solicit and integrate patient, family, and team feedback to refine communication approaches and enhance mutual understanding.

Lead interdisciplinary discussions by employing advanced facilitation skills, ensuring alignment with objectives, and fostering team collaboration.

Leverage advanced technologies to enhance communication efficacy and accessibility for diverse populations.

Develop and implement innovative methods to educate, inform, and engage diverse audiences, ensuring complex health information is accessible and empowering to all stakeholders.

Identify evidence-based guidelines to develop engagement materials.

Create materials using clear, concise language and visuals to accommodate health literacy levels and ensure comprehension across diverse populations.

Design tailored materials integrating individual goals, values, and contexts.

Implement systematic methods to evaluate the impact of materials on outcomes.

2.2i Apply individualized information, such as genetic/genomic, pharmacogenetic, and environmental exposure information in the delivery of personalized health care.

Explain the importance of integrating genetic/genomic, pharmacogenetic, and environmental exposure information into patient assessments and care plans.

Consult with specialists to ensure accurate interpretation and application of complex data.

Educate patients and others on the relevance of genetic and environmental information using clear and accessible language to promote understanding and informed decision-making.

Incorporate advanced genetic/genomic, pharmacogenetic, and environmental data into comprehensive individual or system-level plans, ensuring alignment with the latest evidence-based guidelines.

Utilize advanced tools and resources to optimize clinical decisions impacting patient care.

Develop and deliver tailored communication strategies to explain complex genetic and environmental data to patients, families, and team members, ensuring their understanding and active participation in care decisions.

2.2j Facilitate difficult conversations and disclosure of sensitive information.

Deliver sensitive information clearly and compassionately, ensuring the patient, family, or team understands the content.

Use empathetic verbal and nonverbal communication strategies to create a supportive and nonjudgmental environment during difficult discussions.

Lead difficult conversations with diverse patients, families, and healthcare teams while acknowledging different perspectives.

Address conflicts arising during difficult conversations using advanced communication skills.

2.3a Create an environment during assessment that promotes a dynamic interactive experience.

Initiate assessments using professional communication to build trust and encourage open dialogue.

Utilize open-ended questions to actively engage patients in sharing health history, concerns, and goals.

Tailor communication to create a caring and respectful environment based on patient needs.

Identify and address communication barriers by using innovative strategies and tools.

Synthesize comprehensive histories incorporating social, behavioral, physical, and cultural influences.

Use open-ended questions to encourage patients to describe their health experiences in their own words.

2.3c Perform a clinically relevant, holistic health assessment.

Identify and prioritize assessments addressing the patient’s immediate needs and presenting symptoms.

Collect subjective and objective data to support clinical decision-making.

Apply clinical judgment to determine assessment sequencing and urgency.

Adjust assessment priorities in real-time based on clinical judgment and patient feedback.

Prioritize assessments based on the patient’s immediate needs and presenting symptoms.

Follow policies and procedures when utilizing equipment and conducting point-of-care testing.

Determine the necessity of point-of-care testing based on clinical indications.

Identify and manage errors in point-of-care testing.

Collect and handle specimens according to established policies and procedures.

Recognize and analyze normal and abnormal health findings.

Consult clinical guidelines and evidence-based resources to verify deviations from normal findings.

Differentiate between findings requiring urgent versus routine follow-up and communicate appropriately with healthcare team members.

Identify patterns in abnormal findings and correlate them with potential underlying conditions.

Use abnormal findings to prioritize interventions and refine care plans.

Synthesize normal and abnormal findings in relation to the patient’s disease process.

Incorporate family dynamics and support systems into the assessment process.

Identify community-level factors affecting holistic patient care.

Analyze data trends to assess their influence on patient well-being.

Integrate clinical findings with environmental and societal data to develop comprehensive, person-centered care plans.

Document accurate assessment findings in the patient’s health record.

Provide patients with clear and comprehensible explanations of assessment findings to ensure their active involvement in care decisions.

Communicate key findings to the healthcare team during handoffs and case discussions.

Collaborate with healthcare team members to discuss and interpret findings, contributing to informed clinical decision-making.

2.3h Demonstrate that one’s practice is informed by a comprehensive assessment appropriate to the functional area of advanced nursing practice.

Gather assessment data relevant to the patient’s condition and advanced practice specialty.

Apply advanced nursing knowledge to interpret assessment findings within specific functional areas.

Synthesize and prioritize data to guide practice decisions effectively.

Demonstrate clinical reasoning and decision-making skills in analyzing complex cases and refining patient care plans.

2.4a Synthesize assessment data in the context of the individual’s current preferences, situation, and experience.

Make evidence-informed decisions based on an understanding of the individual needs of the patient.

Refine data continuously by integrating feedback from diverse sources and adjusting for the evolving patient status.

2.4b Create a list of problems/health concerns.

Identify key health concerns to generate a problem list based on assessment data from the patient and other sources.

Share the problem list with the healthcare team to facilitate collaborative planning.

Incorporate input from interdisciplinary team members to prioritize the problem list and integrate it into the care plan.

Update the problem list as new information becomes available, ensuring its accuracy and relevance.

2.4c Prioritize problems/health concerns.

Organize health concerns based on immediacy and potential impact on the patient’s well-being.

Consider patient preferences when prioritizing identified health problems.

Analyze the interplay of multiple health concerns to anticipate and mitigate potential complications.

Facilitate team discussions to ensure alignment on prioritization and care strategies.

2.4d Understand and apply the results of social screening, psychological testing, laboratory data, imaging studies, and other diagnostic tests in actions and plans of care.

Interpret basic diagnostic results, distinguishing normal from abnormal findings.

Interpret abnormal diagnostic findings in the context of individual health status and conditions.

Integrate diagnostic data into the initial plan of care, ensuring alignment with the patient’s clinical needs.

Recognize the interactions between multiple diagnostic findings and their cumulative impact on patient health.

Engage in interdisciplinary discussions on diagnostic findings to inform and guide care decisions.

Identify the etiology and underlying factors of various conditions.

Communicate key findings from assessments clearly to team members.

Anticipate relevant assessment and diagnostic tests for different health conditions.

Provide informed recommendations regarding diagnoses to the healthcare team.

Analyze practice situations holistically using an unbiased and systematic approach.

Ask targeted, evidence-based questions to assess diagnostic priorities.

Recognize emerging patterns in patient data to identify potential diagnoses using advanced reasoning frameworks.

Develop initial differential diagnoses aligning with the patient, system, or population context.

Synthesize contextual factors into diagnostic and care decisions.

Anticipate potential complications or barriers to formulate diagnoses and implement proactive strategies to address them.

Reassess diagnoses and decisions based on evolving clinical evidence.

Incorporate the best available scientific evidence, clinical guidelines, and research findings into decision-making.

Apply advanced scientific concepts to healthcare delivery.

Seek out and integrate new scientific knowledge into practice to enhance patient care.

Engage in reflective practice to evaluate decision-making processes and assess for potential biases.

Gather perspectives from both the patient and team members.

Respectfully acknowledge the contributions of all team members to the planning process.

Encourage patient participation in plan development to foster ownership and autonomy.

Collaborate with the healthcare team to make informed healthcare decisions.

Advocate for the patient in healthcare team planning.

2.5b Organize care based on mutual health goals.

Collaborate with patients and stakeholders to set achievable goals reflecting their priorities and capabilities.

Organize activities logically to address prioritized goals efficiently.

Implement care activities to monitor progress toward health goals, adjusting as needed.

Incorporate patient feedback to refine care organization and enhance goal achievement.

2.5c Prioritize care based on best evidence.

Refer to the best available evidence to prioritize interventions with the most significant impact on patient outcomes.

Explain the rationale for prioritized interventions.

Identify necessary resources to meet goals.

Synthesize short- and long-term care priorities based on patient feedback, evidence, and goals.

Revise priorities as new evidence, conditions, or team input emerge.

Synthesize evidence to support prioritization and decision-making.

Advocate for evidence-based priorities aligning with stakeholders' needs.

Identify interventions supported by clinical or policy guidelines.

Ensure chosen interventions prioritize safety.

Assess patient responses to interventions and adjust as needed to ensure safety and effectiveness.

Implement evidence-based interventions to address complex healthcare delivery issues.

Evaluate interventions for effectiveness and safety, contributing to continuous quality improvement.

Apply emerging evidence and innovations to enhance patient care outcomes.

2.5e Anticipate outcomes of care (expected, unexpected, and potentially adverse).

Identify potential outcomes of planned interventions.

Monitor for signs of adverse or unintended outcomes and take prompt action when needed.

Develop plans to prevent and mitigate potential adverse outcomes.

Utilize clinical reasoning to anticipate complex or unexpected outcomes of care.

2.5f Demonstrate rationale for plan.

Identify relevant evidence to support decision-making.

Align plan of care rationales with patient preferences and values.

Reflect on the plan of care rationales to ensure alignment with best practices and goals of care.

2.5g Address individuals’ experiences and perspectives in designing plans of care.

Explore the patient’s lived experiences and perspectives.

Consider cultural, social, and emotional factors when designing care plans.

Maintain an ongoing dialogue with the patient to adapt the care plan as their needs evolve.

Seek opportunities to understand experiences different from one's own to ensure comprehensive care.

Synthesize input from all team members into a cohesive, comprehensive plan.

Collaborate with the team to reduce patient risks and prevent harm.

Educate the patient and other stakeholders on strategies to minimize risks and promote adherence to preventive measures.

Lead the healthcare team in prioritizing risk mitigation strategies.

Implement strategies to reduce healthcare risks through team collaboration and leadership.

2.5j Develop evidence-based interventions to improve outcomes and safety.

Document relevant evidence to inform intervention selection.

Prioritize interventions enhancing patient safety and minimizing potential harm.

Evaluate data and measure the impact of interventions on patient outcomes, safety, and satisfaction.

Adjust interventions based on data and outcomes to improve effectiveness.

Lead the care team in implementing strategies to optimize patient safety and outcomes.

Communicate potential person-centered solutions in the absence of established evidence.

Advocate for the adoption and evaluation of innovative use of technologies or practices.

Follow established protocols and guidelines to implement the plan of care accurately and efficiently, ensuring it is tailored to the patient’s needs.

Coordinate with team members to ensure seamless implementation of the care plan.

Implement protocol-driven care based on the patient’s specific context.

Anticipate and address barriers to care implementation, evaluating continuity, patient outcomes, and effectiveness.

Provide concise, clear verbal updates to team members during shift handoffs and interdisciplinary meetings.

Document and communicate care delivery using electronic health records (EHRs) and other digital tools.

Explain care activities to the patient to ensure understanding and engagement while soliciting feedback.

Use appropriate communication tools and strategies to effectively share patient care updates, ensuring clarity and collaboration across healthcare teams.

Facilitate real-time communication among team members across multiple modalities to enhance care delivery.

Deliver patient education to empower individuals to participate actively in their care.

2.6c Delegate appropriately to team members.

Identify tasks suitable for delegation based on the scope of practice and team members’ competencies to ensure patient safety.

Provide clear instructions when delegating tasks to team members.

Verify team members’ understanding of delegated tasks.

Monitor delegated tasks and provide feedback as needed.

Delegate tasks according to expertise and roles within the team.

Foster a collaborative environment where delegation is structured and well-coordinated.

Address and resolve delegation-related issues promptly and constructively.

Observe patient responses to care interventions and compare them to expected outcomes.

Identify and address deviations from the plan promptly to maintain continuity of care.

Communicate observations to the care team to support coordinated monitoring efforts.

Monitor data and implement interventions to mitigate potential complications.

Incorporate feedback from patients and team members to refine the care plan.

2.6e Model best care practices to the team.

Analyze evidence-based protocols and best practices during care implementation.

Implement evidence-based practices.

Advocate for evidence-based and best practices in healthcare delivery.

Seek and incorporate constructive feedback from peers and supervisors to foster continuous learning and improvement.

Apply best care practices within the team, ensuring alignment with current evidence.

Address gaps in team practices, suggesting actionable improvements to enhance care quality.

2.6f Monitor aggregate metrics to assure accountability for care outcomes.

Compare care outcomes against institutional or national benchmarks to assess performance.

Develop and implement action plans to address identified gaps in care outcomes based on metric analysis.

2.6g Promote delivery of care that supports practice at the full scope of education.

Demonstrate an understanding of the roles and capabilities of all team members, ensuring their full utilization within the care team.

Validate care delivery alignment with institutional policies and professional standards.

Advocate for team members’ ability to practice at their full scope of education and training.

Participate in reviewing and refining policies to support full-scope practice within the care team.

Provide constructive feedback on policies and processes to enhance transparency and accountability.

Identify and address ethical implications in care policies to promote fairness and transparency.

Collaborate with key stakeholders to ensure policies reflect person-centered care principles.

Evaluate the effectiveness of policies and propose evidence-based improvements.

2.6i Apply current and emerging evidence to the development of care guidelines/tools.

Use current literature to identify gaps in existing care guidelines by analyzing current literature and opportunities, recognizing areas for improvement.

Collaborate with interdisciplinary teams to review emerging evidence and adjust care tools accordingly.

Lead the integration of current and emerging research into evidence-based care guidelines to enhance patient-centered care.

Evaluate the effectiveness of implemented care tools by analyzing patient outcomes and refining guidelines based on emerging evidence.

Advocate for including diverse, high-quality evidence from interdisciplinary fields to develop culturally competent, individualized care tools.

2.6j Ensure accountability throughout transitions of care across the health continuum.

Provide comprehensive handoffs during transitions of care using standardized communication tools.

Develop follow-up plans to ensure continuity of care post-transition.

Keep all relevant team members informed about transitions to prevent gaps in care.

Implement transition plans anticipating and mitigating risks across the care continuum.

Manage transitions effectively, ensuring all roles are clearly defined and executed.

2.7a Reassess the individual to evaluate health outcomes/goals.

Conduct routine reassessments to evaluate progress toward health goals.

Compare current findings with baseline data to identify changes in the individual’s condition.

Share reassessment results with the healthcare team to facilitate coordinated evaluation and decision-making.

Integrate physical, emotional, social, and cultural factors into reassessments to comprehensively evaluate health outcomes.

Synthesize patterns and trends in reassessment data, linking them to the effectiveness of interventions.

2.7b Modify plan of care as needed.

Identify necessary adjustments to the plan of care based on feedback from the patient and team members.

Propose changes based on clinical guidelines and emerging patient needs.

Engage the individual in discussions about plan of care adjustments to align with their preferences and values.

Collaborate with the interdisciplinary team to ensure care plan modifications are holistic and evidence-based.

Provide a clear, evidence-supported rationale when modifying the care plan in discussions with the team or patient.

Identify specific patient factors that may necessitate deviations from standard practice.

Suggest potential adjustments to care practices to better suit the individual’s context and goals in collaboration with the team.

Propose evidence-based alternatives based on the evaluation of current standard practices, meeting the individual’s needs.

Consider ethical implications when deviating from standard practices, ensuring ethical and patient-centered decision-making.

2.7d Analyze data to identify gaps and inequities in care and monitor trends in outcomes.

Collect and review patient data to identify variations in care delivery and outcomes across different populations.

Recognize patterns in data suggesting disparities or inconsistencies in outcomes among different groups.

Engage with team members to validate observed gaps and explore their potential causes and solutions.

Conduct in-depth evaluations to determine the underlying causes of gaps in care and inequities.

Analyze trend data to assess the impact on healthcare outcomes.

2.7f Synthesize outcome data to inform evidence-based practice, guidelines, and policies.

Gather and organize outcome data to identify key findings relevant to practice and policy.

Evaluate the quality and applicability of outcome data to current evidence-based practices, identifying areas where updates or refinements may be necessary.

Translate complex outcome data into actionable insights for practice improvement and policy development.

Advocate for system-wide adoption of practices informed by synthesized data to enhance patient outcomes.

Monitor the implementation of evidence-based guidelines and evaluate their impact, refining practices as needed.

2.8a Assist the individual to engage in self-care management.

Provide step-by-step instructions and demonstrations for specific self-care activities.

Communicate ways individuals can take small, achievable steps toward self-care independence using positive reinforcement.

Assess the patient’s ability to perform self-care tasks, offering assistance and support as needed.

Design personalized self-care management plans aligned with the individual’s health goals and lifestyle, adjusting the plan as needed.

Support individuals in making informed decisions and encourage ownership of their self-care practices.

Help individuals identify and overcome barriers to effective self-care.

Collaborate with families or caregivers to support the individual’s self-care efforts in a coordinated and sustainable manner.

Identify the individual’s preferred learning style, literacy level, and learning readiness.

Use plain language and visual aids to convey complex health information effectively.

Employ standard educational materials and strategies to enhance understanding.

Develop individualized educational plans informed by learning theories and methodologies.

Adapt materials and approaches to align with the individual’s developmental stage, cultural background, and values.

Assess the effectiveness of educational strategies and adjust them as needed to support self-care.

Provide clear, step-by-step instructions for health promotion and illness prevention practices.

Distribute valid and reliable educational materials to support understanding of self-care practices.

Develop comprehensive education plans addressing health promotion, prevention, and disease management.

Incorporate the latest research, guidelines, and cultural considerations into educational content for individuals and families.

2.8d Respect individuals and families’ self-determination in their healthcare decisions.

Honor the individual’s right to make healthcare decisions, even when they differ from professional recommendations.

Use empathetic and nonjudgmental language when discussing healthcare choices.

Ensure individuals and families have all the necessary information to make informed decisions.

Advocate for the individual’s and family’s right to self-determination.

Reflect on personal biases to ensure respect for diverse perspectives in healthcare decisions.

Guide individuals and families to access healthcare resources.

Identify when additional resources or referrals are needed to support self-care management.

Create personalized resource plans integrating personal, system, and community assets.

Advocate for expanded access to resources to address gaps in care and support.

Conduct comprehensive assessments to identify self-care management needs and barriers.

Design individualized, evidence-based self-care strategies that align with the patient’s preferences, goals, and capabilities.

Develop multi-faceted self-care strategies integrating behavioral, clinical, and environmental components.

Align evidence-based self-care strategies with broader care plans to ensure continuity of care.

2.8g Incorporate the use of current and emerging technologies to support self-care management.

Provide instructions for using self-care technologies effectively and safely.

Assess selected technologies to align with the individual’s technical skills and access.

Explain the benefits and limitations of using technology for self-care management.

Utilize technology for self-care management based on the patient’s needs and preferences.

Monitor the impact of technology use on self-care behaviors and health outcomes, adjusting as needed.

Demonstrate active listening and empathetic responses during counseling sessions.

Describe counseling techniques.

Identify barriers to self-care and develop strategies to address them.

Utilize comprehensive counseling strategies integrating multiple therapeutic techniques to advance wellness and self-care management.

Apply effective counseling techniques, adjusting strategies based on individual responses.

Manage resistance or ambivalence during counseling, fostering trust and collaboration.

Identify existing personal, community, and system resources available to the patient for self-care management.

Recognize limitations in available resources that may hinder effective self-care.

Conduct thorough resource adequacy assessments to promote self-care and address gaps as needed.

2.8j Foster partnerships with community organizations to support self-care management.

Identify community organizations aligning with the patient’s self-care needs.

Maintain accurate records of community partnerships utilized in care planning.

Establish partnerships with community organizations to enhance self-care support networks.

Assess the impact of community partnerships on patient self-care outcomes and identify areas for improvement.

Identify the individual’s care needs, available resources, and potential barriers to continuity during transitions.

Participate in follow-up care to support seamless transitions and ensure all stakeholders are informed.

Develop continuity supportive plans of care addressing immediate needs and long-term goals, integrating input from the individual and their family.

Collaborate with the care team to align continuity efforts and ensure a smooth handoff.

Communicate each care team member's roles and responsibilities to facilitate care coordination.

Monitor the effectiveness of team collaboration and refine actions as needed to clarify roles.

2.9d Recognize when additional expertise and knowledge is needed to manage the patient.

2.9e Provide coordination of care of individuals and families in collaboration with care team.

Facilitate communication and coordination among team members to ensure consistency in care delivery.

Identify and organize resources needed to support individuals and families during care transitions.

Track the effectiveness of care coordination efforts and make necessary adjustments to improve outcomes.

Maintain clear and updated documentation of care coordination efforts in the patient’s health record.

Utilize communication pathways among providers, systems, and community organizations to support patient care coordination.

Assess the efficiency and clarity of current communication processes through observation and feedback.

Recognize common barriers to effective communication and develop strategies to address them.

Critically analyze communication pathways, considering technological, interpersonal, and systemic factors.

Propose actionable recommendations to optimize communication pathways across diverse care settings.

2.9g Develop strategies to optimize care coordination and transitions of care.

Identify gaps in current care coordination processes during transitions of care.

Ensure strategies align with available resources, evidence-based practices, support services, and technological tools.

Leverage advanced tools and technologies to enhance care coordination and transitions.

Test strategies to evaluate feasibility and impact before broader application.

Facilitate communication and collaboration among providers across different systems.

Validate that care coordination efforts prioritize patient goals and preferences.

Gather feedback on the coordination process to identify areas for improvement.

Engage with cross-system teams to coordinate care for complex cases, ensuring consistency and alignment.

Track and analyze care coordination outcomes to refine processes and enhance efficiency.

Guide peers and teams in adopting best practices for cross-system care coordination.

2.9i Analyze system-level and public policy influence on care coordination.

Demonstrate an understanding of how public policies and system-level regulations affect care coordination.

Use data to assess the impact of system-level factors on care coordination outcomes.

Develop recommendations based on data analysis to inform policy and organizational decision-making.

Monitor and evaluate the ongoing impact of system-level and policy changes on care coordination.

Contribute to proposals for system-level changes aimed at improving care coordination.

Engage stakeholders in discussions about the benefits and challenges of proposed changes.

Support efforts to track the impact of system-level changes on care coordination.

Develop plans for sustainable improvements in care coordination at the organizational level.

Utilize systems to monitor the impact of implemented changes and refine strategies.

Advocate for the widespread adoption of successful care coordination models across health systems.