In 2007 IHI launched initiatives to translate the Triple Aim concept into specific actions for change. The result was a model and a set of design concepts to fulfill the Triple Aim in practice.

Care coordination is a necessary foundation to achieving the “triple aim” of health reform – improved patient experience of care (quality, access and reliability), improved population health, and per capita cost control. This position statement articulates the essential role of the registered nurse in the care coordination process.

Development of a model for the registered nurse in care coordination and transition management provides nurses the opportunity to develop the knowledge, skills, and attitudes to be a resource to the team and to patients, and to contribute to high-quality patient and organization outcomes.

As recent studies suggest, professional nurses have the potential for significant contributions to patient-centered, cost-effective care through the care coordination role. In order to fully achieve this potential, clear models and outcome measures are needed which specify the context for care coordination, identify nursing competencies, and value the nurse’s role within the health care team.

This position paper reflects the current state of ambulatory care and the crucial role of the RN as a care provider, care coordinator, and care partner. It also highlights potential role changes and adaptations for the future.