Care coordinator with patient-centered medical home (PCMH)

lamazeteacher · Sep 5, 2012

I recently accepted a new job as a Care Coordinator for primary care practices. I won't start for another month or so, so I have time to gain a little more knowledge. I don't know a whole lot about patient-centered medical home, but I would love to know more. Is anyone currently doing this? If so, what do you think of it? What do you do on a daily basis as Care Coordinator?

I'm not able to give you information about your new job, but I do want to say that this situation borders on the incredible! Surely the requirements and job description given to you in the early stages of your application have you a clue about what work was involved in the position.... Did your interviewer not provide some information or ask how you would use your skills when carrying out the tasks in the position?I know that changes in our profession have brought new titles for jobs, and I've had an interview in which I was asked if I thought "coordinator" was appropriate in the name of one. I've been an Inservice Coordinator providing educational programs for all hospital staff, including medical interns (when I thought I'd been hired for the nursing Dept. only); and I was an Infection Control Coordinator when that title was originated, in the 1960s. No one knew what that entailed, least of all the hospital's Administrator..... It was challenging to have those jobs, on the "cutting edge" of their existence.However the more I see Job titles like yours, and others of that type these days, the more I think people who make them up, are validating their existence, by doing that. It also seems that a new graduate might get some experience in the fields in which this position is, before "coordinating" two areas in orthopedics and urology. However you've already been hired to do whatever the departments have in mind, already; and I certainly don't want to "rain on your parade". Although orientation time was outlined, it doesn't seem that anyone occupied that position before, to provide realistic information while you adapt. Warning bells sound all over this situation, and I hope you'll have appropriate "On-the-job-training", to be able to perform it. I decided to go around the community talking/interviewing other Infection Control nurses at other hospitals (mostly teaching facilities), to learn the standards being used, forms necessary, and other elements of the job. We decided to have monthly meetings to keep abreast of requirements in the field locally and elsewhere, as it was such a new concept. That capacity has grown to be a much respected and constantly evolving vital role, with licensing dependent on an adequate program.Perhaps that will happen in your job. It will be necessary to identify urinary infections promptly in patients immobilized by a cast around the pelvis or elsewhere that impinges on mobility and creates pain. There must be new ways casts can be made impermeable to urine so the stench I recall being embarrassing for the patient, and a challenge for nurses,will not happen. I hope that has been handled already. It would also be extremely helpful if Home Health agencies could be involved in findings that occurred in hospital, and after discharge, if only on computer records that are interchanged. It's always seemed odd to me, that exchanging nursing information (not against HIPPA) doesn't regularly take place, rather than having to go on physician summaries only when getting patients there.

tamilynn · Sep 6, 2012

Hi , Congrats on your new job!It is a new need in nursing. Your the resource between patient , medical care and home. The goal is to decrease ER utilization and prove its effective. Managing care and identifying needs and building a foundation of expectations of care and results with in our communities!!!!! Best of Luck.... I will be doing this work soon!!!

HouTx, BSN, MSN, EdD · Sep 6, 2012

PCMH's are on the horizon for the US. It is one of the lynch-pins of Healthcare Reform. This type of care arrangement is new, so you may not find a lot of jobs similar to yours . . . yet.

Based on what I know, your new job would probably be like a super case manager; making sure that no one falls through the cracks in our complex health care delivery system. Such as - helping patients though the confusing world of dealing with specialty consultants; analyzing patient teaching needs & hooking them up with educational resources; facilitating referrals; communicating with insurance companies; reviewing and reconciling prescriptions, etc. It certainly won't be dull.

Congrats on getting in on the ground floor in what certainly will be an increasingly popular model of health care.

agrayRN, MSN, APRN, NP · Sep 7, 2012

Thank you all for your posts! I guess I should have provided a bit more background on myself. I've been a nurse for about 6 1/2 years (LPN for 1 year, RN for 5 1/2). I am currently in ambulatory care (clinic) and have been there for about 4 years, so I already know some of the physicians and patients with which I will be working. The woman who will soon be my manager did tell me a bit about the position, but both she and the job description were a bit vague. I did get the feeling that I would be doing exactly what you said, HouTx - coordinating all aspects of their care in the ambulatory setting. I already do a lot of these things for patients at our office, so I am feeling confident about this new position. I am really excited about it - I think it's right up my alley. I did have a feeling that it was a bit new, so I wasn't sure if I would get any responses to this. Thanks to you all for your help! :)

28andcountn · Sep 7, 2012

I have been the care coordinator for a pediatric office for about 4 years now as part of the state medical home initiative. What every one has been saying is on target with what I do for my patients. I write alot of letters of medical necessity, reconcile plans of care from home care agencies and act a point person for families and specialists and community resources. There is alot of patient follow up, and education involved as well. I am also involved in quality improvement of the clinic. The medical home concept seem to be a big buzz word these days but basically it is a way to provide families and patients with a place they can depend on for all of there care, for our practice it means that we stay on top of all aspects of patient care. We may not write all the prescriptions of follow all the testing but we see the "big picture" and try to decrease the fragmentation of care. It is care in a team approach where the family and providers work together for the patient.

This was a new position when I started as well and it did take a while to get into a routine and the role is still evolving. I do really think that this is a growing field in health care. I find a great deal of satisfaction in my work and I think it is a great way to use your nursing experience within the out patient setting.

I hope you will enjoy your new role. It is difficult to get started in an entirely new direction in unknown territory but it is very exciting too! Best of Luck!

jeffsher · Sep 8, 2012

I recently accepted a new job as a Care Coordinator for primary care practices. I won't start for another month or so, so I have time to gain a little more knowledge. I don't know a whole lot about patient-centered medical home, but I would love to know more. Is anyone currently doing this? If so, what do you think of it? What do you do on a daily basis as Care Coordinator?

I work as a PCMH Case Manager (embedded in a clinic, employed by an insurance company), and our primary duty is disease management of patients with COPD and Heart Failure, although with all of the co-morbid conditions, deal with many other diseases and their management.

Broad answer as to what I do on a daily basis? Anything and everything. My day starts out checking my voicemail and then daily patient weights, and I then start calling patients at home to check on them (routine follow up calls), in between seeing patients in the office. I also do chart reviews of patients in the hospital, calling SNFs to get a weekly update, call the in-patient care manager to discuss a patient that is hospitalized; and the list goes on.

We have protocols for dealing with Heart Failure and COPD exacerbations, and also titrate insulin. The day never goes as planned, as there is always someone calling with an acute problem-if you are obsessive compulsive, that in itself can be unnerving, as you have to put off your routine calls to another day, but not unlike hospital nursing where you have to deal with an acute problem in addition to the other things you do (the difference being that you are responsible for "catching up", whereas in the hospital the next shift picks up the things you didn't get to)

Other things I often do are consulting with the PCP, calling the Aging Office to refer for services, calling a DME to setup oxygen, calling for an appointment to get someone in to the specialist asap, consulting with a pharmacist if there are med issues...

It's basically micro-managing those with complex chronic health issues.

Despite this neverending workload, I love my job. With all of the changes coming to healthcare, this is the place to be. Good luck!

jeffsher · Sep 8, 2012

Yes, your ambulatory care experience will be invaluable. I worked 5 years in-patient (Peds), and then 17 years Primary Care (Peds, Family Practice, and Internal Med). I currently case management elderly and some younger adults, although we will soon be managing all age groups.

The field is still evolving, so you will probably be seeing a lot of changes in the coming years.

SHGR, MSN, RN, CNS · Sep 28, 2012

I work as a PCMH Case Manager (embedded in a clinic, employed by an insurance company), and our primary duty is disease management of patients with COPD and Heart Failure, although with all of the co-morbid conditions, deal with many other diseases and their management.
Broad answer as to what I do on a daily basis? Anything and everything. My day starts out checking my voicemail and then daily patient weights, and I then start calling patients at home to check on them (routine follow up calls), in between seeing patients in the office. I also do chart reviews of patients in the hospital, calling SNFs to get a weekly update, call the in-patient care manager to discuss a patient that is hospitalized; and the list goes on.
We have protocols for dealing with Heart Failure and COPD exacerbations, and also titrate insulin. The day never goes as planned, as there is always someone calling with an acute problem-if you are obsessive compulsive, that in itself can be unnerving, as you have to put off your routine calls to another day, but not unlike hospital nursing where you have to deal with an acute problem in addition to the other things you do (the difference being that you are responsible for "catching up", whereas in the hospital the next shift picks up the things you didn't get to)
Other things I often do are consulting with the PCP, calling the Aging Office to refer for services, calling a DME to setup oxygen, calling for an appointment to get someone in to the specialist asap, consulting with a pharmacist if there are med issues...
It's basically micro-managing those with complex chronic health issues.
Despite this neverending workload, I love my job. With all of the changes coming to healthcare, this is the place to be. Good luck!

This sounds very similar what I do, except I am not employed by an insurance company- I work for the clinic (affiliated with a large hospital).

I really created and developed my own job (still evolving and growing!) so yes, it can be done. My ambulatory experience is similar in length to yours. Don't be scared! PM me if you would like (any of you that are doing PCMH case management) if you want!! I love the collaborative aspect and the continuity of care that I can provide. It's so fulfilling.

Yes, I shadowed anywhere I could (the asthma clinic. the peds endo clinic. Other big family medicine clinics/FQHCs. etc) and read a ton. Find a mentor if you can. Make friends with people who can help you (for me? a drug rep who introduced me to a lot of people in the diabetes community, the case managers at the hospital, etc etc). Network your butt off like your patients depend on it, because they do!!

lhyde · May 10, 2013

We are currently in the process of developing a medical home at our pediatric practice. Your post was very exciting to me. What you describe is what I see happening here. I only know one other person who has a similar job at another office but she does not have a job description yet either. We are still in the process of developing a job description. I would really like to connect with other nurses with similar jobs to see what their job description is and to perhaps form a support network. Would you be willing to share your job description? Are you aware of any organizations or support systems for Medical Home Care Coordinators? Do you know of an conferences or organizations that would be good resources? I appreciate any suggestions.

sewinnett, ASN, RN · Feb 18, 2018

This reply you gave was very helpful to me. I am going to be starting as a Pediatric Care Manager in 2 weeks and with 5 years in Pediatric Home Care for medically complex children, I am pretty excited to be making this move. My family asks me what I will be doing and your explanation will be very helpful to them as well as I tell them I will only know more as I go along! :)

CharleeFoxtrot, BSN, RN · Feb 19, 2018

It's basically micro-managing those with complex chronic health issues.

I am also a care manager embedded in a PCP clinic, and in addition to the above we attempt to educate folks about their own health care through motivational interviewing techniques. If you aren't familiar with that there is a lot of information on the web. Bottom line of my job is to help people stay out of the hospital by engaging them and empowering them to actively participate in their own health maintenance.