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Nurse care coordinators weave positive patient outcomes


Christine Truiano, RN, BSN, MBA, knew she was doing her job well when a patient called and asked for a dental referral. “Although this was not typically within my scope of practice, I felt honored that this patient really trusted me for everything,” said Truiano, a clinical care coordinator at NYU Hospital for Joint Diseases.

Truiano is one of six clinical care coordinators across NYU Langone Medical Center’s four hospitals. The role was created within the past year and essentially establishes a nurse-led command center to facilitate communication between patients and providers. Truiano calls patients prior to their joint replacement surgery and explains what to expect during their hospital stay. She also screens patients for potential challenges after release from the hospital. Truiano is the liaison between the patient and the healthcare team during a hospital stay and between the patient and their healthcare service providers after discharge.

“Before we had clinical care coordinators, patients would have surgery, and then after the surgery they would be approached to discuss discharge planning,” Truiano said. “Planning ahead of time gives families time to think about facilities and insurance benefits they have access to.”

The goal of the care coordination program, called guided patient services, is to improve communication with patients and with the numerous providers involved in a patient’s care. Although the concept may seem long overdue, factors such as legislation and clinical data are raising care coordination’s profile.

“The Affordable Care Act included provisions for care coordination, and this really put the concept of care coordination on the map because it was the first time we had seen the term in legislation,” said Mary Beth Newman, RN-BC, MSN, CCP, CCM, past president of the Case Management Society of America. “The goal of care coordination is to make sure a population’s needs are understood, that a process is in place to develop a plan of action and that there is good communication between healthcare teams.”

Readmission rates raise stakes

Research findings about high readmission rates of certain patient populations also ratcheted up the motivation to design new methods of healthcare delivery, Newman said. One landmark study, published in The New England Journal of Medicine in 2009, showed that nearly a fifth of more than 11 million Medicare beneficiaries who had been discharged in 2003 and 2004 were rehospitalized within 30 days, and 34% were rehospitalized within 90 days. The researchers estimated that in 2004 these rehospitalizations cost Medicare $17.4 billion.

“We had to figure out how to prevent those readmissions and facilitate safe and effective transitions of care,” Newman said. “Case managers can coordinate everything from a patient’s psychosocial needs to health literacy to the living situation after discharge.”

The Hospital Readmissions Reduction Program, which launched in October, also fueled the motivation to expand the role of case managers. Under this program, the Centers for Medicare & Medicaid Services started reducing payments by up to 1% for hospitals with too many 30-day readmissions for myocardial infarction, heart failure and pneumonia based on national data.

“It is a very good time to be in case management because a whole new set of stakeholders is paying attention to our role in reducing readmissions,” Newman said.

Pilot programs build momentum

Truiano was one of the first clinical care coordinators to be hired at NYU Hospital for Joint Diseases. The program was lauded so highly by patients and physicians that the medical center added clinical care coordinators in the cardiovascular and neurosurgery departments in the fall of 2012.

“Before the surgery the clinical care coordinators ask a series of health and well-being questions that uncover who may be at risk of readmission after surgery,” said Ana Mola, RN, MA, ANP, director of care transitions at NYU Langone Medical Center. “We try to address these issues before and after surgery.” To ensure all healthcare providers know the patient’s complete health history, the clinical care coordinator communicates with the surgeon, home care services, an acute care facility, a community cardiologist, an endocrinologist and a primary care provider.

With a single point person connecting the providers and the patient, the goal is to keep everyone more engaged in the process, Mola said. “The patients now have the support to be accountable for their recovery, and the providers will be knowledgeable about what happens when patients go through the care transitions.”

Physicians buy into new nurse roles

In May 2010, a team of physicians at John Muir Health in Contra Costa County, Calif., tried care coordination by piloting a patient-centered medical home. Four primary care physicians in one practice worked with an RN case manager to coordinate care for the most vulnerable elderly patients, such as those with recent hospitalizations or multiple admissions or ED visits. An LVN, who focused on chronic disease education for less acute patients, teamed with the nurse case manager. “In a busy day physicians do not have the time to find resources for patients, and the medical assistant may not have the resource knowledge, so having a case manger with this information is invaluable,” said Susan Jones, RN, BA, CCM, the program’s lead case manager.

At first, the physicians were unsure what to expect from the new nursing role, but that quickly changed. The program was so successful that the number of physicians participating in the medical home jumped from four to 12 within 11 months. The program has extended to another primary practice site. The program’s benefits also are clear from the drop in readmission rates. According to data from July through September, control group patients were admitted to the hospital 2.42 times more frequently than patients in the medical home.

“The joy for me is watching patients and caregivers interacting directly with the primary care provider,” Jones said. “You can have a patient in the office and grab a doctor down the hall to deal with an issue immediately. We don’t have to wait until people are admitted to help them.” •


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Heather Stringer is a freelance writer.

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