Cobb searches for RNs with experience in home care, the ICU, or ER, as well as with critical-thinking skills. Candidates should be confident and articulate as well. "Ambulatory care coordinators have to think on their feet and develop relationships with their patients. If they sound the least bit uncertain, the only place that patient is going to go is the ER," she says.
Follmer measures the success of the program by "providing the most appropriate care at the most appropriate time," which can result in decreased readmissions and ER utilization.
For example, the care coordinators can connect a patient with congestive heart failure to a physician's office for a dose of Lasix or a breathing treatment rather than sending the patient to the ER.
"We look at every case that's been readmitted to see if the patient could have been diverted elsewhere," Follmer says. In fact, the care transition coordinator team follows the patient to see what treatment readmitted patients required, and if that care could have been provided elsewhere.
'An optimum level of wellness'
At Sharp Rees-Stealy Medical Centers, a multispecialty medical group of more than 500 physicians at 22 locations in San Diego County, "the goal [of the care coordinator] is to bring the individual to an optimum level of wellness and functional capability," says Janet Appel, RN, MSN, director of population health and informatics.