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How would you describe care coordinators’ role in iCMP?
As we look across the continuum of care delivery, there is increasing collaboration between inpatient and ambulatory nurse care coordinators and social workers, who have become critically important in ensuring high-quality safe patient transitions and assisting patients in managing their health needs more effectively.
How do they do this?
These expert nurses are deployed to ambulatory practices and integrated into the care teams within primary care. They receive ongoing nursing practice development from Lisa Wichmann in Care Coordination. Lisa has formed an effective team of clinically expert nurses with a commitment to excellence in relationship-based care and truly knowing their patients and families holistically. Some are currently enrolled in a nurse coach certificate program, which has further advanced their expertise in engaging patients in meaningful health care relationships and healthy behaviors.
What results has iCMP seen?
Lisa and her nurses have been able to demonstrate the impact of the professional nursing practice in reducing overall health care costs and achieving improved outcomes for high-risk patients. iCMP is an example of positive patient and cost outcomes that can be achieved by nurses practicing in ambulatory settings. They are collaborating in inter-professional teams within practice settings and across the health system and into the community to insure patients’ needs are heard and met. Their work is groundbreaking.
How does Care Coordination make patient care more
It’s going to sound simple, but it’s by knowing what patients think they need and helping them get what they need when they need it. That could be anything from a change in medication to services in the community to new knowledge on how to manage their disease or their health.
What are some of the other ways Care Coordination is
improving patient care?
Other examples include care coordinators’ participation in daily inter-professional rounds to develop daily care and discharge plans and weekly high-risk rounds, as well as innovation in care transitions to the community. Care Coordination also identifies patients at high risk for hospital readmission using a modified “LACE” tool, an evidence-based assessment that predicts patients’ risk for hospital readmission. This new information will be used to standardize discharge interventions and improve care transitions for those patients at greatest risk for readmission.
Read more about Care Coordination and the iCMP in this week's issue of BWH Bulletin.