I’ve been thinking about my time as a care coordinator a lot recently. Before I joined the team at Activate Care, I was a care coordinator for a long-term services and supports (LTSS) program in Greater Boston. My job was to provide outreach, care planning, and health and wellness coaching, as I connected our enrollees with social services and community resources. Naturally, one of the hardest parts of the job was outreach. Based on my experiences, I have empathy for COVID-19 contact tracers who are only reaching 45% of contacts, on average.
I know that we can do better. But that belief doesn’t change the fact that this is an extremely difficult task. In my LTSS program, we had to follow state Medicaid mandates around outreach and enrollment, including a minimum of three outreaches to potential enrollees. The first step is a phone call, and if I got a hold of a potential enrollee on the first ring, that was really good. Unfortunately, 80% of the time the phone number and contact information were wrong, so I had to follow up with the enrollee’s doctor’s office to request the enrollee’s latest contact info (which was often a negotiation, even though we had the appropriate data-sharing agreements in place.)
Armed with the latest contact info, if I still couldn’t get in touch with the enrollee, my job was to show up at their house or listed residency, which was sometimes old or incorrect information. How invasive is that? Who is comfortable with this situation? We can do better. All I had to show that I was there to help the enrollee was a packet of paper and a little badge to signify my role. Contact tracers aren’t going out into the community, but their role is not dissimilar to mine. For care coordinators across the country, the job of going into people’s homes or homeless shelters will likely never change. But what about all the other parts of the job? What about when I finally make contact with a client and get them engaged?
We need to know where people are in the system
The biggest challenges we face as care coordinators are the member’s willingness to engage, our ability to contact the members, and IT capabilities. In my case, I could not access the EHR, so I didn’t know when the member’s appointments were. I couldn’t call them when they were likely to engage with the healthcare system. One time, I had met a woman member of our program at the hospital for an initial meeting, and when I went to contact her for a follow-up regarding medical equipment, her phone was out of service. It was like this for at least two months. I tracked down her next of kin - in this case, her son - who informed me that she typically gets pneumonia every winter, so she will likely return to the hospital soon, and they’ll get a call regarding her admission. About a month later, I happened to be downtown and randomly crossed paths with her. The work of a care coordinator is too important to be left to chance encounters. We need access to real-time data, ideally through an HIE or HMIS integration, in a care coordination system that is designed to help us do our jobs. The EHR itself is not that system, but the data inside the EHR is mission-critical.
We need to know our clients’ medical histories
As a care coordinator, I would often find myself going into someone’s home. Taking a trauma-informed approach to care, I know that asking someone to share their diagnoses is an uncomfortable and potentially triggering event. What if they are incontinent? What if they were recently diagnosed as HIV-positive? Have they had to share this information dozens of times with different providers? There is also usually some medication management that needs to get done. Many members simply don’t know what meds they’re on. Care coordinators need medical history, labs, meds, allergy reports, and more. This information is critical to succeeding in my role, and with proper training, care coordinators do handle this information responsibly. The technical integrations are the easy part. Our program managers need to advocate for getting this information into our hands. One way Activate Care helps is by integrating with HIEs to share data, then using permissions and roles to ensure the right information gets into the right hands at the right time.
We need access to critical information and real-time alerts
If I was coordinating care for a woman with a history of violence towards children, I should have had advance warning not to ask about their kids. If I was coordinating care for a man with a red alert on his EHR file, that red alert should have been shared with me before I entered his home, even if I didn’t have direct access to the EHR. Too many care coordination programs put the onus on the care coordinator to find out this information. The better approach is to leverage care coordination technology that can pull all this information together automatically from multiple systems and then present it to care coordinators in an easy-to-understand way. This capability is critical for ensuring the safety of both care coordinators and members.
Get in touch
Since 2013, Activate Care’s tools have been used by thousands of professionals to improve the effectiveness, quality, and safety of their community care coordination programs. If I can help answer any questions about our platform, you can always request a demo or shoot me an email at email@example.com.