Care coordination with doctors, other nurses, and various hospital and clinical staff have always been an important part of the nursing profession. While most people may think of specialty hospitals, such as a children’s hospital or cancer center as being team hospitals, it is often the task of nurses to make sure teamwork is central to any medical department. But, the responsibilities of coordinating care do not end with keeping the lines of communication open between various medical technicians, doctors, and patients. Different team members handle insurance concerns, verify referrals from specialists, help handle a patient’s emotional and spiritual needs, communicate with families and more. In short, leaving a nurse to coordinate hospital teams can lead to less time for those same nurses to connect with patients.
A Lot to Handle
Registered Nurses quickly learn that they will work long hours and the works they do are extremely intense during their shifts. High stress is a given, and those who are assigned coordination duty feel the pressure even more. One way to avoid much of the impact of this stress, and avoid mistakes is to break up the different elements of care coordination and take them one step at a time.
Nurses need to encourage coordination within the practice, while also coordinating between primary care hospital teams and specialist teams. They may also need to coordinate a patients’ transition between being an inpatient and an outpatient and assure that they are aware of any community support that may be available.
Finding the Right Approach
While nurses need to be ready for various curve balls that come their way in the course of a day, staying on top of care coordination will help them manage different situations as they arise. A good place to start is with a patient compliant protocol, or PCP. By assuring that each patient has a PCP, a care coordinator can be confident that there is a frame of reference for each patient, and there is something concrete that team members can refer to.
For each patient, a primary care team is usually the central focus, and depending on the complexity of their health issues this may branch out to other teams, such as a specialist or outpatient teams. It is here where it is important to determine the complexity of the individual’s care needs and delegate portions of care coordination where necessary. Each member of the primary care team, as well as associated teams should understand what their role is concerning a patient’s care, and complete notes should always be noted clearly in a patient’s chart.
Role of the Patient, Their Family, and Community
As important as a patient’s care is while at the hospital or clinic it doesn’t stop when the patient walks out the door. It can be a challenge to see that the patient and their support system are compliant with a care plan, but a care coordinator needs to do their best to see that this is done, as the patient represents the most important part of any care team.
A patient’s willingness to make the proper lifestyle changes and keep in step with their care plan can vary quite a bit, and some need more support than others. It’s a good idea to enlist the help of family members, although ultimately patient confidentiality needs to be protected as well.
Communities may also have resources that offer support and/or education about different health concerns. There may be a class on how to make dietary changes to prevent diabetes or a support group for those who are undergoing chemotherapy and their families. Patients can also be encouraged to reach out to the clergy and other members at their place of worship.
More and more often when it comes to patient care, registered nurses are given a significant role in making sure the patient gets the care they need. With so many components in play, any nurse would have some concern when it comes to getting everything right. However, total patient care is hardly a one person job. The key is to keep the lines of communication as clear as possible and to make sure everyone understand their part in each patient’s care plan.
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