| 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.