From Theory to Practice: The Development of a Care Coordinator Role

From Theory to Practice: The Development of a Care Coordinator Role

The emergence of the care coordinator role has shaped the modern healthcare industry in the US, adding a level of connectivity between hospitals and patients that had not previously existed. Where did this role come from? And why did it need to be developed? We will look at one example where the care coordinator role grew organically and helped to change the delivery of care at one facility.

By 2009, things had reached a tipping point at Harvard Vanguard Medical Associates’ Wellesley Office. Located in a suburb of Boston, the practice was growing, teams were expanding and the concept of comprehensive primary care was shifting – something new was needed within the structure of the health center. Initially, the nurses and doctors simply identified the need for some type of system that could help with organization and patient outreach. Then, realizing the urgency of the matter, they formed a committee to jumpstart the effort.

The Emergence of the Care Coordinator

The Harvard Vanguard Medical Associates (HVMA) Wellesley office consisted of 3 Internal Medicine Groups, numerous Specialty Groups, Pediatrics, a Lab and a Pharmacy. One of the Internal Medicine groups, comprising three physicians and two nurse practitioners, formed the “Clinical Outcome Committee” in early 2009. The committee was tasked with “developing methods, and more specifically a role, to help improve the patient care model,” according to Jane Hammond, a Nurse Practitioner at HVMA, and a member of the committee.

As one of the senior members of the committee (she was an N.P. for 38 years at HVMA and a team leader within the practice), Hammond understood that the system that was in place was no longer adequate to handle all facets of in-patient and out-patient care. The committee decided that a care coordinator role was necessary, but exactly what this entailed would require months of deliberation and meetings.

The meetings focused on:

  •         Establishing a health coach/care coordinator who would maintain contact with patients
  •         Improving patient self-monitoring and reporting (Chronic Disease Management)
  •         Easing pharmacy visits between appointments
  •         Depression assessment, monitoring
  •         Exercise, improvement of basic functioning for patients
  •         Making community resources more available, easier to use
  •         Establishing a population management system/position
  •         Improving obesity and CV risk reduction workgroups

After much thought, and a thorough planning process, the role was created and the specs were finished. The care coordinator would be the “go-to person” for patients after they visited the office.  The care coordinator would handle all of the aforementioned tasks, and the physical office would be adjusted to accommodate the new position.

We developed an After Visit Sheet which the patient would hand to the care coordinator, who would then direct patient to the lab/X-Ray, set up Imaging Studies, book follow-up appointments and explain referrals to Specialists,” said Hammond. “An office was set up near the exit to the waiting room and a sign above reading ‘Check Out.’ The Coordinator also gave out his/her card to the patient if any questions arose later.

Better Follow-Up = Better Care

The new role wasn’t enough to transform the care model, however. The committee came up with the idea of an after-visit summary (AVS). It began as a simple slip of paper that was filled out by the clinician and then passed to the patient. As technology evolved, so did the AVS – the document was entered into the computer system, printed and then delivered to the patient by the care coordinator (when available). The patient would receive an explanation of the results and the next steps. Further correspondence that would occur after the appointment was also outlined, and a plan was created to maintain constant communication (if necessary).

Communications technology, while existent, was certainly not the same in 2009 as it is in 2015, but the idea behind the AVS remains the same. Now, a better, more integrated system exists, which helps limit manual recordkeeping and eases follow-up care.

The care coordinator worked with the staff and the AVS infrastructure to keep patients, nurses, and doctors informed. There were many trials, starts and stops, and adjustments made to the role and the AVS, but the effort continued unabated since that first committee meeting.

Results and Progress

And how did it all work out? Well, according to Hammond, it certainly helped the practice and eased the daily jobs of many people within the practice.

“Overall, the Care Coordinator Role has been a huge success. It has cut down time for Clinicians at the end of visits as well as giving the patients a contact for follow-up car,” said Hammond. “The AVS is a very useful tool, and can be used as a teaching aide for patients. I found that patients do not always hear everything that is said at the visit. The AVS includes any future appts, vital signs at the visit, results of any stat labs or X-rays, and educational materials. If a patient was in for Orthopedic problem, exercises and plan of care is included.”