Document Type


Publication Date

Spring 2022

Date of Final Presentation


Committee Chair

Teresa Serratt, PhD, RN

Committee Member

Leslie Falk, DNP, RN

Coordinator/ Chair of DNP Program

Pamela Gerhke, Ed.D., RN, DNP

Abstract/ Executive Summary

Background: Mental health (MH) disorders are among the leading cause of disabilities in adults, with an even greater prevalence among Veterans who served in combat. Forty percent of troops returning from combat zones report suffering from post-traumatic stress disorder (PTSD) or depression and 33% report trouble accessing MH care. Access to care is directly influenced by care coordination procedures in health care systems. If care coordination is poor or lacking, patients remain in settings that are inappropriate for their level of care. Implementing a care coordination program can improve care transitions, provide the necessary support for patients to successfully transition, and improve access to specialty MH for patients who need a higher level of care.

Project Design: The purpose of this project was to 1) review the literature to determine best practices for health care transitions, 2) develop a pilot quality improvement program based on the best evidence, 3) implement the pilot, and 4) obtain feedback from facilitators and participants to enhance care transitions and sustain project interventions. The intervention was to implement a nurse-led standardized care coordination pilot program in the MH department to facilitate effective care transitions from MH to Primary Care (PC), specifically aiming to improve the process and patient experience.

Results: Results demonstrated that the interventions improved Veterans’ experience of care, provided them with the necessary education and support, and facilitated the continuation of care in a setting appropriate to meet their needs. Further inquiry is needed to identify best practices in translating the term “care coordination” into the providers’ standard medical language to improve their awareness and understanding of this model of care.

Recommendations: The results of the project demonstrated that care coordination programs can be useful in MH and PC and can be adopted in other health care settings where care transitions occur. It is essential to develop partnerships with organizational leaders and staff to design a multidisciplinary approach for care transitions to be effective. Care coordination activities that focus on timely communication and shared decision-making will ensure the continuation of care across settings and promote positive patient outcomes.

Conclusion: Effective care transitions require collaboration among health care professionals. A care coordination model can improve patient outcomes. The care coordination pilot established guidance related to care coordination activities needed for successful care transitions to occur, improved care transitions between MH and PC, supported patients in managing their health care during care transitions, and provided a framework for future improvement work.

Included in

Nursing Commons