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.