Care Transformation Center Blog

Coordination isn't just for patients: How one system is 'coordinating the coordinators'

by Rebecca Tyrrell and Carolyn Buys

As providers expand care management services across patient populations, managing the various stakeholders involved in coordinating care is becoming more challenging.

A high-risk patient diagnosed with cancer, for example, could simultaneously be managed by an oncology nurse navigator and a primary care coordinator. However, these individuals may not communicate regularly or have a clear understanding of who ultimately "owns" certain coordination functions. As a result, efforts may be duplicated, certain tasks might fall through the cracks, and patients may become overwhelmed.

One system in the Midwest has created an innovative program for "coordinating their coordinators" by using three distinct strategies for managing disparate stakeholders involved in a patient's care plan:

1. Designating a primary coordinator based on patient need

The system assigns care coordinators to patients based on risk level and treatment type. For example, if a cancer patient is primarily being treated with chemotherapy, his or her care coordinator will be based in medical oncology. In the case that the patient requires interventions outside of cancer care, the medical oncology care coordinator steps out of the active role, but continues to connect the patient with resources and serve as the main point of contact.

The same policy holds when a patient has both a primary and a specialty care coordinator. Before the reorganization, both primary care and oncology care coordinators were making follow-up calls 48 to 72 hours after a patient's discharge. Now, there is a standardized process so that if the patient is admitted for an oncology-related reason, the oncology care coordinator will make the call, and vice-versa.

By tying care coordinators to patients themselves rather than to physicians, the system is able to provide a seamless experience for patients across the care continuum.

2. Encouraging collaboration between stakeholders

Simply designating a main point of contact isn't enough. To improve coordination between PCPs, primary care coordinators, and oncology care coordinators, the Director of Nursing hosts monthly meetings for all of the coordinators in the system, regardless of specialty.

During the meetings, individuals discuss care coordination strategies and how to reduce duplication of services. In between these meetings, primary care and oncology care coordinators take turns shadowing each other. In doing so, each is able to gain a deeper understanding of patient needs and progress.

3. Standardizing communication protocols

To boost efficacy of coordination between stakeholders even further, the system has developed standardized communication protocols for care coordinators who are managing the same patient.

All coordinators communicate about patient progress both through the electronic health record and over the phone. For online communication, coordinators are trained to use the same types of documentation phrases and formatting so that both parties can understand. This standardization helps providers collaborate on key care decisions and remain fully informed of a patient's progress.



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