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Nursing care coordinators today are asked to do much more with less in managing the health of high-risk and chronically ill patient populations. The COVID-19 pandemic adds another layer of complexity to this already difficult job.

Nurse care coordinators have always been responsible for managing large caseloads of chronically ill patients. The goal is always to help them improve health. So, what has changed since the COVID-19 pandemic began?

During this time of pandemic and resulting economic constraints, nurse care coordinators can expect to be called upon to manage larger, more complex caseloads with fewer resources.

The value that nurse care coordinators deliver now is measured by much more than reduced cost of care, patient satisfaction, and better outcomes related to chronic disease management, although those measurements are significant.

Today, value is also measured by how quickly the nurse care coordinator assesses the chronically ill for additional or changing socio-economic issues and community health care inequity due to the COVID-19 pandemic. Value also is measured by the expediency with which action is taken to facilitate resolution for a larger and more complex case load. 

Crucial interventions

The impact of COVID-19 on communities served by nurse care coordinators becomes even more critical where chronic disease and health care inequity exists and social determinants of health (SDOH) are not favorable.

Due to reductions or closures, some patients sheltering in place are becoming disconnected from community agencies and services that once served them. Others are experiencing a new life event – such as the loss of work, income and health insurance.

Nurse care coordinators have their fingertips on the pulse of available community resources and can quickly make those often life-saving connections.

Web-based care coordination technology tools are available that help health care organizations coordinate care for high-risk patients across the care continuum and support electronic collaborative communication between the nurse care coordinator and the patient’s primary provider at the point of care, regardless of the electronic health record used (EHR) or location.

These tools can enable organizations to move to value-based care, manage total population health, ensure appropriateness of care across all care settings, and achieve high-quality outcomes.

When managing high-risk and chronically ill patient populations, it is imperative now to quickly reach out to those patients and screen them for actual COVID-19 exposure, potential risk of exposure, and educational needs related to COVID-19 risk, to ensure that time-critical management occurs.

How to guide high-risk patients

Effective screening requires evidence-based assessments that lead to the development of actionable evidence-based care coordination care plans. These care plans can help address the additional health, SDOH, financial and educational needs of high-risk patients.

There are a range of important questions to ask that can be linked to workflows that uncover SDOH challenges for patients. These questions are important for guiding high-risk patients in a manner that helps prevent and manage exposure to COVID-19.

Some of those questions are:

  • Are you experiencing a decrease of income to cover current expenses?
  • Have you experienced a job loss?
  • Are you currently sheltering in place?
  • Do you have a safe place to shelter?
  • Do you have access to food and meals?
  • What support systems do you have?
  • Do you have medications readily available for the month?
  • Do you need any additional medication resources?

The response to each of these questions may require the nurse care coordinator to complete one or more actionable care plan interventions to resolve an identified problem. This may require collaboration with a patient’s primary provider, health plan, health system, community agency, support system and extended care team.

Standardizing the care coordination process leads to better outcomes. Consistently engaging and linking patients to high-quality community resources, health care providers, services, and care team members can also reduce the cost of care, reduce health care inequity, and improve patient satisfaction.

That’s a great value to the patient, community, and health care organization.

Lisa Hancher, RN, BSN
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