Care Coordinator Responsibilities with Operational Considerations May 2016

Transcription

1 This table was created for an organization that was in the process of hiring care coordinators to ensure they had a strong, sustainable care coordination system. The column Systems, Workflows, Infrastructure Considerations was created to help the practice think about what needs to be in place for care coordinators to be successful in their important work. Care Coordinator Responsibilities with Operational Considerations May 2016 Care Coordinator Responsibility Serves as customer service ambassador and bridges communication between the health center/ provider care team and the patient. Helps ensure patient visits are effective and efficient through Chart Prep: Review upcoming appointments to determine if labs, diagnostic tests, referral and consult report were completed and obtain results as necessary; review health maintenance reminders and notate in chart. Conducts patient recall: Notify patients due for important tests/visits and schedule appointments. Systems, Workflows, Infrastructure Considerations Schedule regular meetings (weekly or biweekly) between care coordinator and care team to improve quality, safety, efficiency, patient experience and care team satisfaction/cohesiveness; have agenda and provide action-based minutes post meeting Ensure norms and training around customer service, including skill with dealing with difficult patients Establish communication standards o All calls/interactions with patient are documented in Intergy and copied to appropriate clinician o Care coordinator will close all loops and circle back to the care team to provide confirmation of completion of requests Use standing/standard orders to facilitate providing care needed to fill chronic and preventive gaps in care (e.g., If patient is due for mammogram, care coordinator may enter order and schedule patient) Establish standard place and method to notate in chart Develop how care coordinator facilitates daily huddles provides electronic huddle notes in each patients chart with results of chart prep, leads huddle, works with MA, etc. just establish how to do this efficiently and with maximum benefit to the care team Create list for which patients will be recalled and how list will be generated and how often. For example (can also add a column for who will run the report and with whom the report will be shared):

2 Coordinates the processing of patient paperwork in a timely manner including but not limited to: disability forms, durable medical equipment authorizations, medication/ treatment authorizations, school forms, etc. Follow-ups with patients who no-show for important appointments and schedule them back; Document communication efforts in patient chart. Type of Care Report Frequency from: Well-child visits Intergy 1 st of month Annual visits Intergy Monthly by patient birthday DM Bundle (A1C, MiAl/Cr, eye exam, Intergy Quarterly foot exam, lipids) Flu vaccine Intergy Monthly during flu season Pneumovax Intergy Standardize how to document when patients decline and when unable to reach patient (e.g., document three calls on three different days in one phone note) Assign disposition of each type of paperwork with focus on reducing administrative burden for clinicians (i.e., fill out as much as possible, use signature indicators, dedicate 10 minutes with clinician to work through paperwork, etc.) (Paperwork and administrative burden is cited as one of the top reasons for burnout; this is an important issue.) Develop standard protocols around no-show contact. For example, a post clinic huddle with clinicians who needs to be rescheduled, who needs education, who should receive a warning letter, etc. has been shown to be effective. Define adequate efforts to contact (e.g., two calls on two different days, letter, etc.) Standardize documentation in Intergy with templates and/or quick texts Collect data to know if efforts to contact no-shows results in an improvement, including time spent on contact efforts, no-show rate, show rate of those that were contacted, etc.

3 Follow-ups with patients following hospital discharge to schedule follow-up with PCP. Map and develop/standardize the process for post-discharge follow-up to include: o List of all hospitals to which patients are admitted along with how the practice is notified of admissions/discharges o Depending on how notified, establish workflow with timeline for how these are processed. For example, may receive notification by checking HIE, receiving faxes or s, or by checking Alliance portal. Create standard script 1 based on a transition checklist (that is integrated into Intergy) for care coordinator and focus on evidencebased best practices o Help patients/caregivers learn diagnoses, list meds with purpose, explain follow-up plan of care, and articulate treatment preferences and goals of care. o Focus on patients with psychiatric and behavioral health issues, including those with substance abuse o Connect patients with community services, including an ongoing feedback loop to healthcare practitioners 2 Consider dedicating certain appointment slots for post-discharge follow-up or devoting resources to a dedicated weekly transition of care clinic Collect and monitor associated metrics: time spent with post-discharge f/u; readmission rate; % contacted within hours; patient feedback, etc. 1 Good resource: Re-Engineered Discharge (RED) Toolkit Tool 5: How To Conduct a Postdischarge Followup Phone Call; found at 2 From CMS Discharge Planning Proposed Rule published November 3, 2015; found at 03/pdf/ pdf

4 Assist in coordination of patient care: Assess for issues that if missed can delay patient care (open referral, lab orders, etc.) Create list of issues with standards for each, including documentation in the EHR. For example (not a complete list!): Discharge notes Referral notes Test results If in chart, make note for huddle. If not in chart, add to task list; continue to look on HIE daily until in chart; notify clinician when in chart If in chart, make note for huddle. If not acknowledged by clinician, route for signature. If not in chart, add to task list; continue to contact specialist weekly for note; notify clinician when in chart If in chart, make note for huddle. If not acknowledged by clinician, route for signature. If not in chart, contact lab. If pending results or no patient did not complete, add to huddle notes in Intergy.

5 Notifies patient of test results. Mails patients copy of test results and, as directed, schedule patients back for follow-up. Assists uninsured patients in applying for medications through the prescription assistance program. Standardize patient notification of test results. Something like We will notify patients of test results within three business days of our receiving results. Clinicians will acknowledge receipt of labs within one business day. All normal results are pushed to portal upon clinician acknowledgement. Patients are notified that normal results will be on the patient portal within three business days (of our receipt of results). If patient preference is other than portal, they will be notified according to patient preference as noted in Intergy. All calls and letters of notification are noted in the EHR. Clinicians will direct care coordinator about specific test results that are not normal by flag/note in EHR. Once abnormal results are communicated, documentation from EHR is routed to clinician. Collect appropriate metrics to ensure policies are followed Encourages patients to enroll in Mi Salud portal. Develop standards around when and how to do this Engage patients to develop the most patient-friendly way to do this. Collect appropriate metrics Develop resource management system that is easy to update, access and use Links patient to enabling services: Refers patient to Community Health Services department and provides information on community resources. Coordinates timely submission of mandated reports for positive test results (e.g. Lead, STDs, etc.). Same as above Develop resource management system that is easy to update, access and use Document in Intergy which community resources patient is using Follow-up with patient to ensure resources are meeting needs and to get feedback about community resources (e.g., helpfulness, ease to access, etc.) add this info/feedback to ongoing resource management system Provide adequate training and build in proficiency testing/monitoring

6 Utilizes a multidisciplinary approach to resolving problems that affect patients receiving timely information and services. Work with the care team and patients to identify a list of barriers and solutions 3 Partner with patients to identify and co-design solutions to problems that affect timely access to the care they want and need, when they need it The project described was supported by Funding Opportunity Number CMS-1G from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. 3 I have some resources to help the team identify barriers as well as to solicit barriers from patients. Just let me know if you want to tackle this - Trudy