When people ask Janet Duni, RN, CCM, MPA, what's required of a good population care coordinator, she says the answer is right on her face. "I point to the sides of my eyes where I have a couple of crow's feet," she says.
Translation? Good care coordinators have lots of experience.
As patient-centered medical homes become more commonplace, so too will care coordinators, a role that Duni believes is perfect for nurses to step into.
"I think a nurse is the best suited to this type of work," says Duni, who's the director of care coordination at Vanguard Medical Group in Verona, New Jersey, and who has decades of nursing experience behind her.
"A lot of the care coordination job is about understanding a continuum of care that a patient will go through," she says, and nurses certainly do. But even beyond the clinical understanding and expertise that's required of the job, care coordinators who come from nursing backgrounds can draw on and transfer other skills that they used when they were bedside nurses.
Like nurses, care coordinators "have many, many irons in the fire each day and keep all patients in [their] line of site," Duni says. Like nurses who care for multiple patients during their shifts, care coordinators must juggle many patients with varying needs and constantly prioritize and reprioritize whose needs are greatest at each moment.
Like nurses, care coordinators must do their work with constant interruptions and a never-ending sense of urgency. Always triaging patients, determining who's the sickest, who needs help right now, who needs help later, who needs a follow-up.
Like nurses, care coordinators must do their work with constant interruptions and a never-ending sense of urgency. Always triaging patients, determining who's the sickest, who needs help right now, who needs help later, who needs a follow-up.
"That type of stop-and-go [environment], and yet getting it all done, and keeping it all afloat… that particular skill set is what you learn as a nurse," Duni says. "You're always doing 10 things at one time, and I think that's unique to nursing." Care coordinators need to understand things such as community services, insurance, rehab, social services, and more. Duni describes patients as the center of a wheel, and all of their needs are spokes. The care coordinator connects all of those disparate pieces to make the wheel turn.
"A care coordinator needs to be able to establish and utilize a network of resources," Duni says.
As the role becomes more commonplace, Duni says she wonders whether, one day, nurses will be able to specialize in care coordination. Training programs are emerging, like the one Duni herself participated in through Horizon Healthcare Innovations, a subsidiary of Horizon Blue Cross Blue Shield of New Jersey, and Duke University School of Nursing and Rutgers College of Nursing.
Duni was part of the first cohort of that program, which aims to provide at least 200 New Jersey nurses with a formal population care coordinator education. She says the two-pronged program started at Duke, where participants learned about the tenets and history of population care coordination, and ended at Rutgers, where the students applied their learning to hands-on work.
Care coordination is gaining traction, but in order for it to really catch on and for more nurses to get into the field, payers need to come forward with payment plans for it, Duni says.
For example, Eileen Carlson, RN, JD, associate director of government affairs for the American Nurses Association, told me last year that a new Medicare rule that will pay nurses when they help patients make the successful transition from hospitals to other settings is one of the biggest things ever to happen in the world of coordinated care.
By all accounts, care coordination pays off for patients, who benefit from the help they receive in scheduling appointments, managing medication, and monitoring health.
Also significant is the payoff for providers and payers. Duni also says that data from one of the acute care facilities they work with shows that the readmission rate for Vanguard Medical Group is significantly lower than for their peer practices.
At the end of the day, care coordination carries with it a simple principle for a complicated role: "Get in there early and often to help patients find ways of being engaged in their care," Duni says.
Alexandra Wilson Pecci is an editor for HealthLeaders.
