Coordinated Care

  • Patient Story:

    An elderly patient with multiple chronic conditions called 911 fourteen times, resulting in four inpatient admissions and three Emergency Department visits. Identified as being high-risk and in need of further care coordination, this patient was assigned to a BSWQA RN care manager. After four to six weeks of weekly phone calls, the RN care manager was able to gain the patient’s trust and work collaboratively on a number of key issues that helped prevent their use of emergent services resulting in no more hospitalizations, ED Visits or ambulance trips. The patient now knows they have someone to call and trusts that the RN Care Manager will get back to them. Money saved by eliminating three trips to the ED by ambulance – $3,600, eliminating four inpatient visits – $48,000, eliminating three ED visits – $4,500; having a dedicated RN care manager who you can call and trust with your care, PRICELESS!

    Patient Rights and Responsibilities

    ACO Flyer

  • Coordinated_Care

    Communication Across All Sites of Patient Care

    According to the National Quality Forum, “Care coordination is a function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time. Coordination maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and high-quality patient experiences and improved health care outcomes.”1

    In addition to coordination of care that is practice-based through patient centered medical homes, BSWQA has created a centralized care coordination department consisting of registered nurse (RN) care managers, social workers and health coordinators. Centralized care coordination supports complex care management for the highestrisk patients (identified through a risk stratification software tool) and for high-risk transitions of care from the hospital to home. It is considered an extension of the BSWQA physician’s practice.

    BSWQA RN care managers augment physician services for the highest-risk patients by facilitating post-hospital transitions, coordinating specialty visits, assisting with navigating the health system and coaching patients in self-management and wellness. Through shared decision making and motivational interviewing approaches, RN care managers work with the patient and the physician to deliver the tools patients need to reach their individual health goals.

    BSWQA’s team of health coordinators coordinate care for rising-risk patients. Their responsibilities include monitoring emergency department and inpatient transitions and completing protocol-driven patient outreach. The health coordinators work with the health care team from a centralized location and focus primarily on promoting wellness by facilitating wellness office visits with primary care providers. They also monitor patients with chronic diseases and facilitate chronic care follow-up appointments with their primary care provider.

    Elderly, high-risk inpatients with a diagnosis of heart failure, pneumonia or COPD discharged to home may receive additional services from a multidisciplinary transitional care team – APRN, RN, pharmacist and social worker for 30 to 90 days. The services include RN calls, remote monitoring and APRN home visits. The pharmacist reviews the discharge medication list, assesses possibility of reducing the number of medications, as well as potential drug-to-drug or drug-to-food interactions. The social worker assesses barriers to care and connects patients to resources.

    1 National Quality Forum. NQF-Endorsed Definition and Framework for Measuring Care Coordination. [Accessed: January 21, 2007]; Available from: