Whether you are juggling multiple doctors’ appointments or returning to daily life after a hospital admission, staying on top of your health can seem like a full-time job. That’s where care coordinators come in. Care coordinators are registered nurses, social workers, health educators and case managers who help you manage your chronic health condition and stay in touch with you after a hospital stay or doctor’s appointment to ensure you have the resources you need to get and stay healthy.
Keep reading to learn the top 10 things care coordinators can do for you.
1. Help you set and meet healthy lifestyle goals. Care coordinators can work with you to set achievable health goals and prevent chronic disease, such as diabetes and heart disease.
“We use motivational interviewing skills, health education and lifestyle modification discussions to help patients to improve our patients’ knowledge and get them more engaged in their healthcare,” says Misty Landor, RN, MSN, CNS, ANP-C, manager of Emory Healthcare Network Care Coordination.
2. Keep you accountable to your goals. Your care coordinator may reach out to you on a weekly, monthly or quarterly basis depending on your health needs.
“We have a multidisciplinary team of that helps patients get the care they need in the time they have,” explains Landor. This team includes:
- A registered nurse who serves as care coordinator or case manager to oversee chronic disease management
- Licensed social workers who support patients with psychosocial needs, like transportation, caregiver support or mental health care
- Health educators who work with people to develop healthy lifestyle goals
- Care coordination associates who help patients schedule appointments, get prescriptions filled and complete referral forms
3. Connect you with a primary care provider. Care coordinators can help you find a primary care physician so you can see him or her when you have a health need, rather than visit the emergency department.
4. Help you manage chronic disease. “We bring patients with chronic diseases into our disease management program, which is run by a nurse practitioner,” says Varnette Robinson, RN, BSN, lead case manager at Emory Coordinator Care Center. “The disease management program covers diabetes, hypertension, chronic obstructive pulmonary disease (COPD), heart failure and chronic kidney disease (CKD). We also assist patients if they need wound care.”
5. Get your prescriptions filled. Care coordinators can help you get your prescriptions filled and will follow up to ensure you are taking your medications correctly.
“Many times, patients come back to the hospital because they were unable to get their prescriptions filled, perhaps because they didn’t have a caregiver or transportation,” says Robinson.
6. Schedule doctor’s appointments. A care coordinator can help you schedule doctor’s appointments at a time convenient for you.
7. Provide access to mental health care. Care coordinators are trained to identify patients with depression and anxiety, and connect them to mental health resources.
8. Find caregiver or home health services. “We follow patients after they go home and make sure they are connected to appropriate community resources as needed,” says Robinson. “We make sure they have good social support, transportation, food and medication. We go the extra mile to figure out what the patient needs.”
For example, if a patient is discharged from the hospital and does not have anyone to care for her once she is home, the care coordinator will connect her to a community resource that can provide in-home care until she is well again.
9. Prevent hospital readmission. “If the patient is in pain or having recurring issues, we can bring them in to the Emory Coordinated Care Center so they aren’t going to the emergency department. This prevents unnecessary hospital readmission. If we identify any issues during our calls, we bring them to the Center.”
10. Be a source of support. “We are there to support patients 100 percent,” says Robinson. “Getting them what they need when they need it is going to improve their quality of life. We are part of a support system to facilitate them living well.”
To learn more about care coordination at Emory, click here.