3 roles to enhance care coordination

Health care organisations need to coordinate treatment to ensure high quality care for complex patients. Coordination is important within specific settings—such as during an inpatient or outpatient episode of care—as well as across settings, spanning the continuum.

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While coordination and integration models within and across settings vary around the world, many organisations are recognising the need to design new roles to support the coordination agenda.

In an effort to help our members understand the different types of roles other organisations are utilising, we’ve tried to categorise these roles into three types: inpatient care coordinators, clinical patient guides, and disease-specific chronic care coaches.

Let’s look briefly at each of these and how we’ve seen them deployed.

Inpatient care coordinator

Gunderson Health System, a large health care network in the US, has developed a unit-based inpatient care coordinator role supported by clinical nurse leaders. The role is designed to ensure continuity of care across the entire inpatient stay.

Specifically, Gunderson’s inpatient care coordinator oversees management of patient care needs and progress, serves as the primary contact for doctors and other care providers at the unit level, and also assists with care plan development and discharge planning.

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The role produced exceptional results. On-time discharges have increased by 26%, costs per discharge have dropped by 8%, and overall patient satisfaction scores have gone up by 8%.

Clinical patient guide

You may be more familiar with another name for this role—the nurse navigator. Its principle purpose is to better guide patients, particularly those dealing with serious illnesses, through acute inflection points across the care continuum.

The US's Forsyth Clinical Cancer Center, for instance, uses clinical patient guides for several cancer diagnoses. Available for questions 24/7, the guides help patients understand and interpret doctors and refer patients to support services.

Forsyth tracks the impact of patient guides through monthly productivity reports.

Disease-specific chronic care coach

Chronic care coaches—which are based in the patient community, not at the hospital—are not necessarily clinical guides but informed coaches with whom patients identify. As such, we found many instances where organisations deployed individuals with no clinical background to fill this role.

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St. Louis Children's Hospital in the US, for example, selects their chronic care coaches based on the coaches' neighborhoods and their own personal experiences with particular chronic diseases.

This role has produced impressive reductions in hospitalisations for coached patients in St. Louis. Coached patients' hospitalisations fell by more than 50%, compared to the non-coached control group.

Cross-continuum care role framework

We built this new framework for cross-continuum care role profiles. You can use it to evaluate the potential impact of these roles and start building cases for investment at your organisation.

“Cross-continuum


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