Patients with chronic illnesses, accident victims and elders with changing health-care needs are just some of the people who may require a variety of medical services and treatments over time. A care transition coordinator helps patients move through different levels and types of care at different facilities. For example, a care transition coordinator assists patients moving from the hospital to a rehabilitation facility and then to their homes. The coordinator makes sure all the doctors, therapists and other caregivers have the information necessary to deliver care to the patient. At the same time, the caregiver communicates with the patient and his family to make sure all needs are met.
History and Goals
Though the idea of care coordination has existed for many years and case managers have played a role in managing patient care for decades, the formal role of a care transition coordinator coincides with the drive toward health-care reform. Pilot programs such as the University of Pennsylvania’s Transition Care Model have shown that a care transition coordinator can reduce medical costs by reducing or eliminating duplicate services, medication errors and hospital readmissions and increasing positive outcomes and patient satisfaction.
Care transition coordinators are one part social worker and one part health professional. They interact with medical professionals on a variety of levels but are also charged with ensuring the patient has adequate support at home after discharge. In some instances, the care transition coordinator may arrange for Meals on Wheels or visiting nurses or other social services for the patient. Some programs have care transition teams that pair a nurse with a social worker, while others recruit a nurse who also has a social work degree. The New York Academy of Medicine recommends that care transition coordinators have at least a bachelor’s degree in nursing, gerontology, public health or social work. Alternatively, a coordinator could have a bachelor’s degree in psychology, sociology or a related field and two years’ experience in public or private social service, preferably in a health-care setting. Advanced degrees, such as a registered nurse or a master’s degree in social work, are also desirable.
Care transition coordinators should have advanced training and experience in the duties of care coordination. In addition, the coordinator will need continuing education each year. For instance, the New York Academy of Medicine recommends that care coordinators have at least six hours of training each year. Some programs may require care transition coordinators to have certification in specialties such as geriatrics or case management. States may offer their own certification programs, or potential care transition coordinators could receive certification from national organizations such as the National Association of Geriatric Case Managers.
The care transition coordinator works with medical professionals and the patient and his family to foster communications and effective, efficient care. Her goal is to assure quality of care as the patient transitions through the medical system. She regularly assesses the patient, including making home visits in some cases, and works with the patient’s medical team to chart the patient’s progress and monitor how well it follows the plan. She makes sure the patient understands medical instructions and that the medical team understands the patient’s needs and concerns. As the patient’s advocate and the care team’s representative, she tries to make sure everyone works together for the benefit of the patient.
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