Collaborating with the care team to engage patients
Care coordination is essential to improving utilization management. The Patient Care Team often consists of a nurse Patient Care Coordinator (PCC), a primary care physician and someone within the provider’s office who serves as the PCC’s right hand. This person collaborates with the PCC and helps to engage patients and improve patient care delivery. Introducing the Local Care Director (LCD).
In working with thousands of providers over the past 16 years, Continuum’s team has found that the role of a patient advocate within the practice setting is essential to transformational outcomes. A Local Care Director is often the Patient Care Team member who identifies clinically high-risk and at-risk patients within an individual practice. Continuum’s Patient Care Coordinators work closely with the Local Care Director to outline specific plans of action around patient needs, including scheduling overdue office visits or tests essential to disease management, ensuring that the patient is adhering to medication protocols, or facilitating a visit to a specialist at the request of the primary care provider.
Not everyone is well suited to the role of Local Care Director. First and foremost is the need for a certain demeanor; a truly caring nature, patience, persistence, passion and a willingness to continually learn and collaborate with clinicians. “The person in this role must be well-organized, detail-oriented, and have a genuine investment in improved health for patients. Most importantly, they must have outstanding communication skills because they are the eyes and ears within the practice for Continuum’s PCC’s,” said Lyn Sheely, RN, PCC, Continuum Health Alliance.
Some of the other essential qualities and responsibilities include:
- Review gaps in care and facilitate care plan orders.
- Work to develop systems, processes and initiatives to engage outside entities in relevant exchange of information to support case management activities and to ensure coordination of care, health promotion, and the closure of gaps in care.
- Assist in monitoring coordination of care with home care agencies, specialists, or other resources in the care continuum.
- Work with providers and the PCC to identify clinically high-risk, high-need, and potentially high-cost patients.
- Ensure that behavioral health screening tools (depression / substance abuse) are in place and that all patients are receiving appropriate screening and behavioral health interventions.
- In addition, an LCD should possess four key attributes:
- Accountability – Accepts responsibility for all aspects of performance and actions.
- Compassion – Is sensitive to and displays empathy for the needs of our patients.
- Communication – Uses appropriate interpersonal skills, styles and techniques to keep customers informed, and to provide necessary information.
- Strong Clinical Knowledge Base – Understands importance of timely response to clinical updates.
A star Local Care Director, Savita Hosein, embraced the challenge from day one. “I happened to be present at a meeting where this new role was introduced. As the position was described, I knew it was the perfect fit. Because I have worked for the practice for more than 12 years, I know many of the patients well and they trust me. Stepping into this role just made sense,” says Hosein. A former hospital phlebotomist, Hosein joined Advocare Medford Station Internal Medicine in 2002 and has served in various roles during her tenure. “I love what I do and am honored to play such an important part in helping patients obtain positive outcomes through better health access.”
One example where Hosein has impacted care was the case of a middle aged man who had not seen his primary care provider for several years. After multiple phone calls from Hosein, he finally scheduled an appointment in the office. His primary care provider performed a full physical and ordered several tests. The results showed that he was diabetic with an extremely high A1c [test shows the average level of blood sugar (glucose) over the previous 3 months]. Hosein, along with the patient’s primary care provider and PCC, developed a care plan for the patient, including new medications, frequent monitoring, change in diet/exercise, and regular check-ins with Hosein. Now, nearly 18 months later, he is doing much better.
“What makes Savita special is her ability to connect with each patient. They know she has their best interest at heart. In addition, she works seamlessly with the PCCs to meet the needs of the patient and the providers,” said Joy Jandoc, RN, PCC, Continuum Health Alliance.
To discuss how Continuum can improve your coordinated care goals, please contact: Devon Swanson, (856) 782-3300 ext. 2419 or firstname.lastname@example.org