Imagine the following. Your grandmother was admitted to the hospital a few days ago for congestive heart failure exacerbation and is to be discharged from the hospital today. During her hospital admission, she was seen by many specialists that she will need to follow up with after discharge, numerous changes were made to her medications, and she will need to have home physical therapy and get laboratory and diagnostic testing in the near future. You’re at her bedside listening to the discharge instructions and then you take her home. With so many things racing through your mind the next day, you are glad to get a call from the nurse care coordinator (NCC) to see how she how your grandmother is doing and to review the discharge paperwork reviewed!
For so many patients and their family members, this is a real case scenario. Hospitalization can be overwhelming, but the nurse care coordinator is an advocate for the patient and their loved ones. The nurse care coordinator assists the patient by providing support and helping them navigate the medical system to get the care and treatment they need to prevent hospital readmission.
An NCC is an RN who specializes in organizing patient care and treatments by including all members of the patient’s care team. The NCC often focuses on medical conditions such as diabetes, congestive heart failure, asthma, chronic obstructive pulmonary disease (COPD), and depression. Overall, the NCC helps prevent gaps in patient care and assist in transitions of care. The goal is to improve patient outcomes, assist patients in accessing the care they need (especially specialty care), prevent hospital and emergency room visits, and promote a continuum of care for the patient.
An NCC also helps the patient develop a plan of care with goals that they wish to accomplish. This could include checking their blood sugars at least three times a day, getting their hemoglobin A1c under 7%, taking their medications as prescribed, or checking their weight every morning. These goals help keep the patient on track and help them achieve their best state of health. The NCC also connects the patient with other resources to help them reach their goals, such as social work, behavioral health, and outside community support services.
NCCs provide a valuable service to patients, their families, and the care team by working collaboratively with the patient. NCCs help patients achieve their goals and ultimately improve their overall health.