Table 2. Care Coordinators' Job Functions and Activities
Job FunctionsCoordinator 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.