(ED NOTE: When we mulled over the creation of this website, it was obvious that the patient had to play a big role; but, we reasoned, all this digital stuff will do no good, unless we have someone sit down with the patient, upon discharge, and “plug them in” to the tremendous internet and digital assets out there. For lack of a uniform term, we used the moniker “Patient Advocate”, which is under the main menu section of “i-Patients”)


By Debbie Edson, RN, BSN
August 20, 2013

Editor’s Note: The author, Debbie Edson, RN, BSN, is a featured faculty member of the forthcoming webinar, The Art of Embedded Case Management: Delivering High-Quality Coordinated Care in Provider Settings, taking place on Tuesday, August 27.

A traditional home and a patient-centered medical home (PCMH) have many things in common: strong levels of communication, a sense of relationship, efficient financial management and an overall sense that all members are pulling in the same direction despite their different ages, knowledge and day-to-day responsibilities. Both the medical home and the traditional home rely on this sense of coordination to function, or manage, with any semblance of effectiveness.

Patient-centered care coordination is not a new concept to most nurses. The nursing process, as a framework to nursing care, consists of six steps: assessment, diagnosis (identifying the problem), identifying outcomes, planning, implementation and evaluation. It is easy to see how the nursing process aligns with the care coordination standards within the PCMH.

However, care coordination is more than just medical management. It is a broader set of social and community services that includes navigating the patient and family through the healthcare system. The patient with chronic disease (such as diabetes) who does not have reliable transportation to attend physician appointments, grocery shop, or pick up medications, will have difficulty following the prescribed plan of care. Likewise, a patient who has multiple ED visits for minor complaints during the summer months is brought to the attention of a nurse navigator. Investigation by the nurse navigator showed that the patient visits the ED frequently during the summer months because there is no air conditioning at home. Once the navigator got involved, the discovery of a social program through the utility company assisted in the purchase of a window unit air conditioner.

Wherever they are embedded, care managers, or navigators as they are sometimes referred to, assist patients with moving toward self-management of their condition or disease, often empowering the patient to become more engaged in their own healthcare. The difficulty with self-management is that many patients are challenged to follow the prescribed medical regime due to a variety of psychosocial issues. Patient outcomes will vary depending on their condition, of course, but it is also worthwhile to consider that the patient’s ability to participate in their care could negatively impact their outcome.

Filling a Unique PositionAs the navigator builds a trusting relationship with the patient and family over time, she quickly becomes the “go to” person when the patient requires additional community resources or their psychosocial conditions change. As part of the care coordination process, it is important to involve community partners, such as home health, community clinics, SNF, and behavioral health, just to name a few. The navigator remains the primary manager of the patient’s journey of care, overseeing and intervening as necessary as this journey continues with the community providers. This patient-centric network of community partners is connected together through a shared plan of care that is accessible and available. Having the ability to view whether or not tasks on a care plan assigned to others are being completed in a timely manner is of tremendous importance as well, and helps nurses spend more of their time caring for patients and less of their time tracking down whether or not their instructions have been understood and followed.

Being a part of the PCMH allows the care navigator to easily communicate any patient needs or changes to the physician, helping bridge the communication gap between patient and physician. Some of the results of this improved communication and care coordination may include an improvement in quality of care and clinical outcomes, reduced costs, improved patient satisfaction, and a reduction in hospital and ED visits.

It is important for the nurse navigator to take a proactive, rather than a reactive, approach to all patients within the PCMH, especially with regards to health and wellness behaviors. Care coordination within the PCMH is not only connecting patients with appropriate resources, but also coaching them into a healthy lifestyle. This can be accomplished by setting achievable and realistic goals, encouraging self-management, and overseeing health maintenance follow-ups, such as immunizations and preventive screenings.

Because the needs of a patient population can vary, a team-based approach to care coordination within the PCMH may provide the best results. In every population, there are patients who are at at a high risk to be admitted to the hospital, utilize an abundance of resources, or spend a large amount of healthcare dollars. This patient group may be best served by the knowledge and expertise of an RN, APRN, or LPN with experience in complex disease management. While this group may not be large in number, they will require frequent outreach (phone calls, home visits, etc.) to educate, identify barriers to success, and to ensure that medications are managed, family support systems are in place, and appointments are scheduled and attended.

Patients that are of a low to moderate risk could be monitored by a medical assistant, nonclinical administrative staff, or even an interactive voice response system (IVR) for changes or trigger events. A simple screening phone call to this group of patients can be made to evaluate any critical needs or barriers to success. If, during the screening call, it becomes evident that the patient requires more evaluation, than the patient’s case can be escalated to a nurse for additional assessment. This model will target and utilize the licensed personnel to focus in on the patients with the higher risk that need more attention. With this model, a larger population can be reached at a lower cost, and then scaled as the needs of the business (and population) grow.

From Patient to Population

With this infrastructure in place, multiple populations can be easily managed. Organizations such as ACOs, bundled payment programs, employer health programs, commercial payers and multipayers can participate. For example, an organization coordinating care with an initial commercial payer program could quickly grow to a multipayer program and then continue growing to include behavioral health, employer health plans and other populations.

As healthcare transitions from episodes of care to journeys of care, the right technology platform can empower nurse navigators and other coordinators of care. A platform that helps stratify patients by risk, create and share patient care plans, and document encounters is a critical component in this new era of team-based care. Being able to communicate in a secure and timely manner with all of the other providers that may impact a patient’s care makes a care coordination team incredibly effective no matter where they are embedded. A robust technology platform automates much of the implementation aspects of successful care coordination by answering the following:

  • Which patients need care?
  • What care do they need?
  • When do they need the care?
  • Who should deliver that care?
  • Where should that care be delivered?

In today’s environment, technology plays a large part in bringing many of the components of patient care together. Technology can also facilitate and enable team-based care coordination. All of the above can help nurse navigators as well as other coordinators of care do what they love to do the most – provide care for the patient. And, in the world of care coordination within the PCMH, it is important to remember: Navigate the patient home and don’t let them roam.

It is time we embrace the role of technology in empowering team-based care.

Editor’s Note: This article was originally published in the July issue of Case In Point, the leading publication for care coordinators. Learn more here.

Debbie Edson, RN, BSN, lives in Austin, Texas, and is the senior program development consultant at Care Team Connect. She has 30 years of nursing experience, and 16 years as a professional clown, specializing in caring clowning and therapeutic humor. All of this clinical and clownical experience make her training sessions for clients a special kind of interactive fun. Contact:

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