An emerging group of professionals, most often RNs, work across the care continuum to provide ongoing, proactive help at a lower cost to patients with high risk or complex needs.
Healthcare organizations have strict mandates to reduce readmissions, to divert care from the ER to less-expensive settings when possible, and to address population health.
But who takes on these responsibilities when physicians already have too much on their plates?
"I think that, at least for certain groups or pieces of our population, there is a greater need for hands-on support of the patient above and beyond what physicians are prepared for or educated to do, and what office staff can do in the course of the day," says Nancy Myers, PhD, former vice president of population health strategy at NewHealth Collaborative, an accountable care organization formed by Summa Health—a patient-centered population health management organization based in Akron, Ohio.
Enter care coordinators, also referred to as care managers.
Care coordinators, most often RNs, are emerging as the go-to individuals to work across sites—including hospitals, primary care, specialties, and postacute care—to provide proactive help and continuity to patients who are high-risk or have complex needs beyond a single episode of care.
In the first half of 2016, NewHealth Collaborative avoided 300 ED visits and more than 250 hospital admissions as patients were restabilized in their homes by care coordinators, Myers says. By comparison, 370 ED visits and 300 hospital admissions were avoided in 2015.
NewHealth Collaborative, which today has 90,000 members, began its care coordination initiative in 2012 as an effort to contain costs.