(Photo by Janice Petrella Lynch, RN)
The Flemington, N.J., facility started with a breast care coordinator 10 years ago and now has RNs in this role in oncology, cardiology, bone and joint health, bariatrics/weight loss, primary care and multidisciplinary sharing of practices.
"Although we care for different types of patients, we have discovered that we all provide the right services at the right time at the right place," said Mary Whitlock, RN, EdM, patient-centered medical home care coordinator, Hunterdon Healthcare.
Seize the opportunities
The coordinators do not offer quick fixes or resolve concerns for patients, but rather work with them to find answers and seek out appropriate services, while acknowledging cultural diversity, life stories and relationships in those solutions.
"Whether we are transferring a patient from the ED to an inpatient unit or from an inpatient unit to a rehab facility, we have many transitions in healthcare which require our care, attention and focus to detail," said Whitlock, who recognizes the importance of interdisciplinary and patient communication during any transitions.
As one technique to help patients, the coordinators use motivational interviewing, a person-centered, goal-directed counseling approach to keep open lines of communication. With the use of therapeutic communication, they help patients to remain actively involved in their care and increase their motivation to change, according to Pamela Vlahakis, RN, MSN, CBCN, clinical care coordinator, HRCC.
In the process, patients increase their knowledge and learn how to foster self-advocacy and decision-making skills. "As a care coordinator, we know that there is never one solution to patient problems, and we continue to develop the ability to say, 'I have to invent a new pathway for my patient,’" Vlahakis said.
A system that works
Patients are referred to the services by physicians, primary care providers, specialists or community outreach and through email, word of mouth, calls from other departments, internet and self-referrals. Once the referral is made, the care coordinator initially speaks with the patient by phone to establish a relationship and identify his or her needs and concerns.
"The bottom line is that we build a relationship, and patients know they can turn to us for help and guidance about what they need to do next or what services are available," said Cheryl Toner, RNC, clinical care coordinator, HRCC. "We work to secure financial aid for patients in need, and through donations, we have offered patients gas cards, food and other necessary supplies."
Mary Vecchio, RN, MSN, APN, OCN, nurse practitioner, community outreach and education, HRCC, sees individuals at community events such as health screenings and fairs, and uses that time to recommend preventive services, such as breast or prostate exams or colonoscopies.
"What often prevents individuals from following up on a particular issue is the fear of finding something," Vecchio said. "When I tell them about our care coordination service, which is free of charge, they realize that they will not be alone, that they will be supported and guided, if they need follow-up care."
The navigation team refers patients to services within the facility and to their partnering facilities and specialists, depending on the patient’s needs, she said.
Care coordination RNs have numbers that support their efforts, according to Barbara Tofani, RN, MSN, administrative director, HRCC.
Through direct referrals, patient participation in cardiac rehabilitation rates was increased by 20% after initiating care coordination. Advanced weight loss patients reported satisfaction scores in the 99th percentile for those who pursued surgery after using care coordination.
Disability index scores for bone and joint patients increased 58% through interdisciplinary care coordination with patient satisfaction in the 99th percentile.
Janice Petrella Lynch, RN, MSN, is a regional nurse executive.
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