Do You Have a Care Coordinator? – By: Mary Ellen Pratt, FACHE, CEO
More and more practices are employing Care Coordinators to help physicians ensure their most complex patients are actively managed to achieve the best possible outcomes.
Why is Care Coordination Important?
Coordinated care has become increasingly necessary as the chronically ill population grows and our health care system becomes more complex and fragmented. Nearly half of all Americans live with at least one chronic condition. Of these adults, 1 in 4 patients sees at least three physicians and the typical primary care physician coordinates care with 229 other physicians in 117 different practices. It is perhaps not surprising then that people with chronic conditions are at high risk of having poorly coordinated care that results in duplication of lab tests, medical errors and adverse health outcomes.
What is a Care Coordinator?
A promising solution to improve care and achieve desired outcomes is implementation of Care Coordinators in primary care clinics. The Agency for Healthcare Research and Quality defines care coordination as “the deliberate organization of patient care activities between 2 or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services.
Generally led by nurses, these staff members coordinate team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources and their physician. Their objective is to facilitate a “shared goal model” across settings to achieve coordinated high-quality care that is patient and family-centered. Special attention will be paid to managing the chronically ill, promoting evidence-based practices and helping patients learn self-management of their disease.
What can you expect from a Care Coordinator?
Most importantly, a Care Coordinator will establish a stable relationship and effective communication between patients and their primary care practitioner. The Care Coordinator handles the calls and concerns from patients, addressing gaps in care and communication as patients move through the healthcare system (for example: from the clinic to home to pharmacy to hospital). They will identify patients in need of care coordination by initiating outreach to patients by phone or mail; conducting face-to-face patient encounters (sometimes this will be an annual wellness visit so that we make sure we are screening all patients for potential need for care coordination services) and providing social support for patients.
With the support of our Primary Care Physicians and because we are committed to providing the best possible care for our patients, St. James Parish Hospital has started a Care Coordination Program. Potential benefits of care coordination include: reduced hospital admissions, improved quality of chronic disease management, improved patient satisfaction and better access to specialty care.
Two registered nurses have been hired to assist our Primary Care Physicians by reaching out to patients that may benefit from assistance and to facilitate wellness visits, chronic care management and care transitions.
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