The Health series is presented by AdventHealth
If you’ve been discharged after a hospital stay, it can be bewildering to figure out what to do next. Navigating recommendations, prescriptions, or follow-up care isn’t always easy or intuitive, and many patients struggle to prioritize their healthcare in the face of everyday life’s endless list of responsibilities.
That’s where care coordinators come in. “The care should not end at the time of discharge from our facilities,” says Melissa Foster, RN, BSN, a care coordinator with AdventHealth Medical Group. Seen as a “second set of hands” to the office staff, care coordinators “provide support to patients who have been recently admitted to one of AdventHealth’s hospitals or emergency departments.”
DIFFERENT TYPES OF CARE COORDINATORS
There are several clinicians whose job is to help patients after they are discharged from a hospital stay or ER visit. Foster says the following clinicians make up much of AdventHealth’s care coordination team:
Transitional Care Management Nurses are likely the most familiar for AdventHealth hospital patients. They call a patient within 48 hours of discharge to “answer any questions they have and educate where necessary,” Foster explains. “They will also make sure the patient has the ability to pick up medications, offer scheduled follow-up visits…and identify any gaps or barriers to care.”
Emergency Department Follow-Up Nurses are similar, except they support patients being discharged specifically from the ER. If additional follow-up feels potentially beneficial to the patient, the nurse will refer him or her to a different set of care managers for longer-term support—from two weeks to 30 days and beyond. “The number of times we call to check on the patient and the frequency of those calls vary based on the individual patient’s needs,” Foster says.
Social Workers assist with a different set of services. Foster explains, “If the patient doesn’t have insurance or is underinsured, the social worker can provide resources of free health clinics in the patient’s residential area, help navigate through the paperwork needed for applying for disability, etc.” Additional services include “connecting the patient to resources to help with transportation, medication, or financial and housing assistance.”
Diabetic Educators are “highly trained to provide support and education for patients with either type 1 or type 2 diabetes.” Patients supported by Diabetic Educators do not have to be newly diagnosed to receive assistance with “education on the disease, diabetic medications, diabetic diet, and suggested amount and type of exercise.” These clinicians communicate with a patient’s primary care provider to streamline healthcare.
Quality Care Coordinators check for gaps in patient care and quality measures. “They are eager to help patients who are overdue on any preventative screenings such as mammograms, colonoscopies, and annual wellness visits,” Foster explains. These coordinators can be literal lifesavers.
IMPACTS OF CARE COORDINATION
According to Foster, a care coordinator’s goal is to provide peace of mind and clinical support for the patient in order to prevent readmission to the hospital or ER. After the commotion of a hospital stay subsides, patients are better able to focus on recovery instructions. “We notice that there is opportunity for reeducation that the patient may not have been able to absorb at the time of discharge,” Foster explains. “We can also speak to family members that the patient has given us consent to talk to.”
By developing care plans and consulting with patients, care coordinators set goals with each patient and track their progress. They become a liaison between the patient and the primary care provider. “We help communicate patient needs to their provider’s office,” Foster continues. “And we maintain patient confidentiality and care.”
Patients are identified for Care Coordination services if they have an AdventHealth primary care provider and have been admitted to an AdventHealth facility as an inpatient or visited the ER. Care coordinators also assist patients who are uninsured. “We can provide resources or refer the patient to a social worker for available free health clinics, medication, and financial assistance as needed,” Foster explains. “Most often, patients are pleasantly surprised that we are calling them after discharge and very thankful that we are doing so—and free of charge!”