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Characteristics No.* Participants Age, median years (IQR) 48.0 (15.0) ≤40 6 41–50 9 51–60 7 >60 1 Race Non-Hispanic white 19 Other 5 Educational level Associate's degree 10 Bachelor's degree 11 Master's degree 3 Hours per week, median (IQR) 39.1 (3.9) <40 4 ≥40 20 Years in current practice, median (IQR) 2.8 (2.7) <1 4 1–2 7 2.5–4 7 5–6 4 >6 2 Practice Practice type Private 6 Academic/residency 6 Community health center 7 Hospital affiliated/integrated system 6 Locale Urban 9 Suburban 9 Rural 7 Clinicians per day, median (IQR) 10 (13) 1–5 8 6–10 6 11–18 6 >18 5 Specialty FM 13 IM 4 FM and IM 2 Multispecialty 6 US region Northeast 11 South 3 Midwest 5 West 6 Patient population Predominantly white 14 At least 25% minority 10 ↵* Some categories have missing data (respondents did not provide all requested information).
IQR, interquartile range.
Job Functions Coordinator Activities Identify patients in need of coordination •Review high-risk lists •Conduct chart reviews •Assess patients and determine coordination needs Outreach to patients by telephone or mail •Track patients through transitions •Follow-up after hospital or ED discharge •Schedule appointments •Follow up after specialist visits •Reconcile medications •Contact patients who are overdue for preventive or disease-specific screenings •Facilitate self-care management •Assist with goal setting, disease monitoring, medication adherence Conduct face-to-face patient encounters •Conduct one-on-one office visits •Provide patient education/motivational interviewing on chronic disease, weight management, smoking cessation •Accompany patients during physician visits •Serve as patient advocate and health literacy interpreter •Reinforce information and instructions •Visit patients in hospital •Introduce self to facilitate follow-up after discharge •Make home visits •Assess lifestyle, home environment, family composition, medication adherence Provide social support for patients •Link patients/families with community resources •Research and network with private and public agencies •Help arrange housing, fuel, food, transportation, low-cost medications, dental care, crisis intervention •Provide emotional support •Serve as a “sounding board,” “listen and validate their experiences,” give praise and small rewards Collect, manage, and exchange data •Conduct extensive chart reviews and update charts •Establish methods of communication between hospital/specialists and primary care practice •Manage preventive screening, chronic disease, high-risk patient registries, transition of care logs, and provider panels •Share outcomes data with practice members •Report data to funding agencies Support physicians •Conduct previsit planning •Participate in huddles •Identify patients who are overdue for preventive screenings or disease-specific testing •Anticipate needs of office visit Obtain records from hospital or specialists Download results from glucometer Give patients depression screening tools Change length of appointments •Provide reminders to physicians on gaps in care •Develop and implement care plans •Complete advance directives •Develop agenda and case review sessions for faculty/staff meetings Back up clinical and administrative staff •Perform nursing duties •Answer triage calls •Conduct wound care, blood pressure checks, obstetric intakes; give immunizations/intravenous fluids •Assist with insurance issues and authorizations ED, emergency department.
Themes Barriers/Facilitators Sample Comments from Participants Organization/system level Clinical information technology Barrier: Lack of needed functionality “I get frustrated with our data collection program because it is quite limited as to the data I can get. Sometimes I have to run multiple reports then combine them to get the patients I need to track—such as multiple chronic condition patients.” (Coordinator 11) Facilitator: Establishing alternate communication methods “I have built relationships with staff members in medical records at one of our most utilized hospitals, as well as staff members at other physician offices that we work with most often. Early on, I called them and explained who I was and what my role was. I told them what information I would be looking for and why. We have come up with a fax system. This saves me the time that it would take to be on the phone constantly.” (Coordinator 4) Community resources Barrier: Challenges identifying community resources “This has been one of those areas that we have put on the back burner over and over… . We have a spreadsheet in a shared file so we can all add new or revised info about what's available in the community. Keeping the data current is an ongoing challenge.” (Coordinator 7) Facilitator: Strategies for identifying key resources “Our county has a ‘resource jam’ twice a year… . It is a daylong event, local agencies sign up for 15 minute blocks of time and get a table to put out information on… . Fabulous networking goes on… . [In addition,] our local Community Service Consortium puts together a guide to community services, which I hand out to patients.” (Coordinator 11) Facilitator: On-site patient resources “We are extremely fortunate to have a Clinical Psychologist and a Social Worker on sight [sic]. This has been extremely helpful as they are often called to step into an appointment when the patient is being seen. We also now have a PharmD a couple days a week to review patient medications with them too.” (Coordinator 21) Interpersonal level Interactions with clinicians and other health care facilities Barrier: Clinician resistance “At my present position each provider has so few of my patients and we don't work together on a daily basis. It's difficult I think for them to trust me… . Some of them look at it as another intruder telling them what to do with ‘their’ patients.” (Coordinator 17) Facilitator: Strong relationships with clinicians “I have an excellent relationship with the physicians in my office. Not only have I worked with these physicians for nearly 3 years now, but I think the biggest factor is trust. They trust me and my work and my efforts with their patients. They know that I will follow through and keep them informed. Some physicians did give me resistance for quite some time. However, as they began to see the positive results of my efforts, their attitudes changed greatly.” (Coordinator 4) Barrier: Resistance from other health care facilities “I have to admit that being able to communicate with inpatient, home health, hospice and therapists is the one area which still remains terribly undeveloped with our practice. Now that we have electronic medical records, I am able to see the inpatient notes better, but after 3 years of trying, the inpatient/ED [emergency department] social workers and care managers still remain ignorant of my existence. I have been successful on a few occasions when I haunted the hospital halls for the nurse/social worker managing my patient while admitted; but I have to really sell my role to get much interaction.” (Coordinator 15) Facilitator: Strong relationships with staff at outside organizations “I think we are very fortunate to have great relationships with the hospital staff. We work closely with the care coordinators and the social workers/discharge planners as well… . We collaborate with the tertiary care site an hour away for a great deal of the specialty care we can't provide here. They are terrific at sharing! We are working on build [sic] stronger community alliances to support our patients with behavioral health needs as well. Our goal is to truly have a community based practice!” (Coordinator 7) Interactions with patients Barrier: Patient resistance; lack of trust “One major challenge is getting patients to ‘engage’ in care management. Our patients have been assigned to nurse care management due to their pattern of health care utilization. Some of these patients are resistant to talking with a nurse care manager and decline to participate.” (Coordinator 18) Facilitator: Developing trust “One patient after receiving my letter called the office and just wanted to tell the receptionist to give me the message that she did not want any part of my program. The receptionist convinced the patient that she should talk to me directly. After I allowed the patient to vent and ask her questions, by the end of the conversation she said ‘well, you don't sound too bad. I guess you can come to my house.’” (Coordinator 17) Facilitator: Listening to patients “Another thing I have found is that many people just need someone to listen to them and validate their experience. When they've had the chance to talk about their emotions, fears, daily challenges, etc. and someone has truly listened—rather than referring them to yet another person—they often come up with solutions on their own (ie, family, friends, neighbors or community resources they know about, that might help).” (Coordinator 18) Individual level Self-care practices Barrier: Lack of attention to self-care “Just over a year ago I changed jobs because I no longer felt I was taking care of myself—physically, spiritually and emotionally—and it was negatively affecting how I interacted with those I worked with and the patients I encountered—it was scary but necessary and my new position helps me keep the balance.” (Coordinator 3) Facilitator: Self-care practices “There are two things that have been very helpful for me in managing the stresses of so many patients, so little time. They are both things I do for me on the assumption that if I am healthy and serene, I can be more available for those who are not. I take a yoga class right here on the campus once a week. It has been a powerful avenue to increased strength, balance and inner calm. The second is a simple daily practice of staying positive. I start every morning with gratitude for three specific things from the previous day, one thing I am proud of and one thing I am looking forward to … it has really reframed the conversation of the day to one that is positive and upbeat.” (Coordinator 7)
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