New path to patient centered medical home

LadyK,RN · Jun 19, 2014

In effort to manage high risk patients care coordination is becoming very common in the inpatient and outpatient setting. You will have the opportunity to have a great impact on the ability of people with chronic conditions to manage their health care at home. The role is similar to case management and will likely involve a lot of patient education on how to manage symptoms, when to call the doctor vs. 911, etc. Some aspects are a bit like babysitting and can be a little frustrating if you have the perspective that these are adults who should be able to follow instructions. Remember that many patients are completely overwhelmed by their disease process and need guidance and sometimes a cheerleader to encourage them. Many patients appreciate the personal touch that the care coordinator provides and the fact that they have a go to person in helping them to navigate the health care system. This is especially true for people who may have not had health insurance for years and are now accessing care under the ACA. As far as resources, check out the American Association of Ambulatory Care Nurses website (AAACN), I think they have a webinar or courses on care coordination. You can also look at case management/care coordination websites.

toomuchbaloney · Jun 19, 2014

Primary Care Nursing Role and Care Coordination: An Observational Study of Nursing Work in a Community Health Center

To fully support these new functions, reimbursement models are needed that support such non visit-based work and provide incentives to coordinate and manage complex care, achieve improved clinical outcomes, and enhance efficiency.

SHGR, MSN, RN, CNS · Jun 20, 2014

A few things off the top of my head that have helped...

try to meet the patient when they are in the office, even better if the doc can introduce you as a warm handoff. You need to build trust. Face to face is the best way for this. Purely telephonic models do not work nearly as well as hybrid of F2F and telephonic.

Be patient as it takes a long time to get to know people and have them trust you.

Get your own dedicated voice mail line if you can so that people can reach you directly- patients and community people like other case managers, pharmacists, etc. Save every name and contact in the community and network as much as you can- tit for tat.

Have one on one meetings with each provider to review complex patients.

Complex patients are often socially complex, may have mental illness or illiteracy issues, or financial barriers. "Provide more education" is not always the answer for a lot of reasons. Sometimes just listening (and listening hard for that one thing that you can then reframe and restate so that the patient then figures it out) or offering a few "well, what works for some patients is..." and getting them to state their own solid plan.

I spend a lot of time building confidence. We use 1-10 confidence scales with SMART goals.

It can be really fun if you are up for it. The AAFP has a lot of articles on the PCMH model. Also the CMSA is a great resource. Diabetes Care journal for DM-related material. Best wishes to you. Let me know if you want to chat.

xoemmylouox, ASN, RN · Jun 20, 2014

Sounds like a tough, but an amazing & possibly rewarding job. I would say from my experience with patients you will need to utilize all forms of communication. Good luck and remember we are here to support you.

Inori, BSN, RN · Jul 4, 2014

Hello there.

PCMH - patient centered medical home and Collaborative Care that's very similar to what they do at my place they introduced this new concept in 2014. Here's some info i learned from our nursing departmental meetings. Good luck! I found the following helpful. link #1 has a user manual literally with step by step from initial encounter to medication adjustment. I printed the teamcare user manual, 3 hole punched it and its on my desk as my refer manual.

also note there's a big difference between care coordination and case management.

Care coordinator = can be anyone not limited to RN is make sure patient is connected to the resources, making, liasoning working with various specialties in helpign pts get thier appts and pt reminders to keep appts, that pcp has the results from refferals.

Case management = usually RN required, works with PCP and patients, meets with team weekly/monthly with main goal is to ensure that patient is self managing thier disease process, through pt education, medication adherence, counseling, 1:1 encounters, group visits, and works with PCP to adjust medications as needed, and track clinical progress via labs and objective data: BP, A1cs, LDLs, etc. RN case managers work with care coordinators who in turn makes sures pt keeps thier appointments, gets thier refferals done in timely manner and. Key difference CM focus is on clinical end and not so much of did you get an appointment to see XYZ. We about it but delegate it to someone else to do.

NOTE: follow your state board rules for your licensing level. You'd be surprised what non-nursing higher ups ask and don't hesitate to say no. OK good luck :)

CARE COORDINATION = collaborative care,

** TEAMcare > Home - has user manual etc all free info

Collaborative Care | AIMS Center

IMPACT - Evidence Based Depression Care

PCMH Patient centered medical home=

PCMH Home | pcmh.ahrq.gov

Patient-Centered Medical Home (PCMH)