During this time of pandemic and resulting economic constraints, nurse care coordinators can expect to be called upon to manage larger caseloads with less resources.
This makes delivering measurable, quantifiable value to their two key stakeholders — the communities and the healthcare organizations they serve — a simultaneous challenge for nurse care coordinators.
The value that nurse care coordinators deliver now is measured by much more than reduced cost of care, patient satisfaction, and better outcomes, although those measurements are significant.
The impact of COVID-19 on communities served by nurse care coordinators becomes even more critical where chronic disease and healthcare inequity exists and social determinants of health (SDoH) are not favorable.
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Understanding the effects of sheltering in place for high-risk patients
Due to reductions or closures, some patients sheltering in place are becoming disconnected from community agencies and services that once served them. Others are experiencing a new life event – such as the loss of work, income and health insurance.
Nurse care coordinators have their fingertips on the pulse of available community resources and can quickly make those often life-saving connections.
Using technology to standardize care coordination
Web-based care coordination technology tools are available that help healthcare organizations coordinate care for high-risk patients across the care continuum and support electronic collaborative communication between the nurse care coordinator and the patient’s primary provider at the point of care, regardless of the electronic health record (EHR) or location.
These tools can enable organizations to move to value-based care, manage total population health, ensure appropriateness of care across all care settings, and achieve high-quality outcomes.
When managing high-risk and chronically ill patient populations, it is imperative now to quickly reach out to those patients and screen them for actual COVID-19 exposure, potential risk of exposure, and educational needs related to COVID-19 risk, to ensure that time-critical management occurs.
Effective screening requires evidenced-based assessments leading to the development of actionable evidenced-based care coordination care plans to help to address the additional health, SDoH, financial and educational needs of high-risk patients.
A few of the SDoH questions that nurse care coordinators should be asking their patients are:
- Are you experiencing a decrease of income to cover current expenses?
- Have you experienced a job loss?
- Are you currently sheltering in place?
- Do you have a safe place to shelter?
- Do you have access to food and meals?
- What support systems do you have?
- Do you have medications readily available for the month?
- Do you need any additional medication resources?
The response to each of these questions may require the nurse care coordinator to complete one or more actionable care plan interventions to resolve an identified problem. This may require collaboration with a patient’s primary provider, health plan, health system, community agency, support system and extended care team.
Easing the cognitive burden of managing large caseloads and reducing nurse care coordinator burnout requires an automated, best practice workflow tool that organizes and prioritizes patient interactions and care plan interventions, ensuring that those interactions and completion of care plan interventions are timely and lead to successful case closure.
Standardizing the care coordination process leads to better outcomes. Consistently engaging and linking patients to high-quality community resources, healthcare providers, services, and care team members can reduce the cost of care, reduce healthcare inequity, and improve patient satisfaction. That’s a great value to the community, the patient and the healthcare organization.
There is much to learn from today’s challenges, but there are also opportunities at hand to be transformative in how we engage with those we serve.
Source: Becker’s Hospital Review