The Patient Centered Medical Home model is doing a great job improving communication within the practice and outside the practice. In a busy rural practice it is ideal to have a Care Coordinator to assure that all information concerning a patient’s care is funneled through an individual to make sure all information is where it needs to be to give the most outstanding quality care to patients. The role of the care coordinator is to be passionate about quality care for patients in their community, making sure no patient falls through the cracks of an extremely busy practice.
Rural practices are very unique due to the shortage of primary care providers to the patient population. When an influx of overworked clinic staff try to keep up with quality care of their patients there is an increase in Emergency Room admissions, chronic issues, and the overall patient population suffers. The need for Care Coordinators is extremely important.
What does a Care Coordinator do?
Care Coordinators are passionate about the quality of care to patients and their community. Below are some essential components of what the care coordinator should be capable of providing to a clinic.
Care Coordinators:
- Promote and reinforce patient-centered medical home concepts with patients and staff.
- Assist with the development, revision, and coordination of the Plan of Care through collaboration with the multidisciplinary treatment team to meet the patients’ needs effectively and efficiently.
- Develop short-term and long-term strategies in the development of expected patient outcomes; collect data through patient tracking in order to measure outcomes.
- Work collaboratively with provider(s) and other staff to ensure the delivery of quality care to patients to ensure best patient outcomes.
- Assess, plan, implement, coordinate, and evaluate the effectiveness of the patient programs.
- Collect data through patient tracking in order to facilitate patient outcome data collection and analysis.
- Serve as a resource contact and information/education source to patient, families, providers, and/or staff.
- Assist the development, revision, and implementation of patient programs and/or marketing programs, materials, and resources in specialty areas to meet the specific needs of the patient population.
- Define and direct patients and/or families to appropriate resource utilization.
- Develop and maintain effective quality assurance (QA) opportunities using patient data/clinical outcomes; conduct evidence-based improvements.
- Work with providers, staff from other clinic sites, third party payers, families, community resources, etc. to facilitate care of the patient throughout the continuum of care.
- Identify system/organizational processes that may affect effective utilization of resources, timely scheduling of tests, appropriate level of care being given, etc., and collaborates with team members to improve upon the processes.
- Responsible for coordinating and leading patient support groups and/or shared medical appointments.
- Identify practice and/or program improvement opportunities to assist with securing the highest level of payment/reimbursement.
- Maintain knowledge and satisfactorily comply with regulatory and third party payers’ procedures, notification requirements and criteria, documentation required in the EHR, etc.
PCMH-recognized practices believe this is the missing link to being a successful, quality care practice. One practice reported with the Care Coordinator in place there has been a 30% decrease in ER admissions and there is more awareness of self-management of care.
For more information or questions about a Care Coordinator please contact Julie Stephens, Project Director, at j.stephens@NeKYrhio.org.
Article by Julie Stephens, Project Director