The Population Care Coordinator: An Asset for a Provider’s Practice
Posted by Cathy Curley, PhD, RN on October 12, 2017
The Population Care Coordinator (PCC) assists patients in navigating through the healthcare system to improve their health, while maintaining the goals of the patient and provider.
Two part series on Care Coordination Team: part one on Population Care Coordinators. Readmissions, emergency room visits, hospital follow up visits and calls, and medication reconciliation are all hot topics in our health system today. How do we coordinate a patient’s care to include scheduling a hospital follow up visit within seven days of discharge and also ensure essential communication makes its way to appropriate providers from the time a patient is seen in the emergency?
The question is not how but who? Who intervenes, advocates, educates, and organizes the care for our complex and chronically ill patients? The Population Care Coordinator (PCC)! The PCC is a registered nurse (RN) trained in chronic disease self-management, population health outcome measurements, and behavioral health tactics such as motivational interviewing. The role is solidly based in evidence from Stanford University Disease Management models and the Naylor Model of Care Coordination.
The PCC works specifically with patients in our Accountable Care Organization (ACO) who are stratified as high risk for readmission and potential decline in self efficacy. A PCC contacts patients within 48 hours of hospital discharge to identify immediate opportunities that may lead to readmission and will to coordinate an appointment with their PCP within seven days. The PCC identifies barriers for the patient to remain at home that ultimately could lead to hospital readmission such as medication discrepancies, home safety, transportation concerns, and other social and medical obstacles. The PCC helps the patient to navigate through the healthcare system, refers to community resources (for example, arranges home visiting nurses), and communicates with the provider and staff the best actions for avoiding a hospital visit. The personalized contact from a RN has proven to be positive for many of underserved patients with limited resources who need support beyond the office visit.
Our preliminary work has shown that our ACO patient readmission rates have declined. Working collaboratively for the best outcomes for our patients is the mission of our Population Care Coordinator team and health system.
