S07 E12 teamBIT Nurses and Care Coordination in Primary Care

In this teamBIT episode, Morgan discusses how nurses can facilitate care coordination in primary care to support complex patients.

Care coordination is less intensive than case management and involves assessing patient needs, connecting with community supports, and maintaining ongoing patient relationships. Morgan describes how, in care coordination, the role of nurses in optimizing care plans is emphasized, especially for frail or complex care patients. Benefits include reducing avoidable crises and ER visits, enhancing patient and family support, and helping patients remain at home longer.

Special Thanks

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Throughout this season you’ll hear from several amazing nurses:

• Angela Wignall is a Registered Nurse who has worked in perinatal health and public health. Since recording this episode Angela has been promoted to the CEO of the Nurses and Nurse Practitioners of BC from her position as Senior Executive Director. Angela is also a board member at the Canadian Nurses Association.
• Diana Boateng is a Registered Nurse and is working on her dual master’s degree in nursing and health informatics. In her Masters, she is a co-op student working with the Innovation Support Unit. Her background is mostly in acute care but she has been interested in exploring what it means to be a nurse in primary care.
• Hannah Roy works as a Registered Nurse in primary care and urgent primary care. She has certified practice in STI management and is completing her Masters degree to be a nurse practitioner.
• Jamie Duteil is a Registered Nurse and the Health System Improvement Director at Health Quality BC. She has managed urgent primary care centres and acute care centres.
• Kacey Wall is a Registered Nurse and a diabetes educator, she has worked in primary care networks and is a team member of the Innovation Support Unit.
• Nikki Kafal is a Registered Nurse and has spent her career working in emergency and critical care settings. She is completing a dual master degree in nursing and health informatics and joins the Innovation Support Unit as a co-op student.

What is Team Up! Team-based primary and community care in action?

A podcast that brings together primary care providers, healthcare planners, patients, innovators and others to talk about the changes that are happening in primary care in British Columbia.

Morgan: Do you want to help
your more complex patients

get the supports they need?

Yeah, me too.

In this team bit, I want to talk
about how nurses can support care

coordination in primary care.

And by care coordination, I mean,
this isn't quite case management.

It's a lighter touch than that.

Care coordination is about optimizing and
coordinating the services a patient needs.

In the community with
and through primary care.

Jamie, a nurse from HQBC, reminded
me of this when we were talking

about how nurses could care for
frail patients living in community.

Jamie: where

you really need to have that connection
with the community supports, your

home care, I think that's where
that care coordination comes in and

assessing what does this client need,
how are we getting the meds to them?

Are they eating?

Are they socially isolated?

Are there.

supports available to help
with their mental health.

I think it's just being able to see
all of those different components

and trying to come up with solutions
for them to be at their best,

Morgan: I think about this for
patients with complex care needs.

Frailty is an example,
but it's not the only one.

So, I've hinted at care coordination,
but what does it include?

I think the activities of care
coordination includes things like

assessing the functional ability of
patients and their families, considering

what supports are available, what
additional supports might be needed, and

then helping to connect to those supports.

And then following along over time,
we are primary care, it's about that

longitudinal relationship and following
along to see if the supports are meeting

the needs or if the needs have changed.

nurses are not the only people that
can do this kind of work for sure.

Care coordination can be done by
different care providers, but I think

nurses are used to doing this kind
of work and they're very good at it.

Angela: when we think about that spoke and
wheel model of a care plan, we often talk

about nurses being right in the center of
the wheel and that wheel being comprised

of a bunch of different disciplines

Morgan: that was Angela
Wignall from NNPBC.

For many people living in community.

That hub should be their
medical home, their patient

medical home in primary care.

Now, full case management is often
part of secondary care services

like home care, mental health
and substance use and others.

And so you might be thinking, we
can't offer that in our clinic.

I agree, the caseload for case
managers could be quite small

relative to the volume of
patients in a primary care clinic.

this is not full on case management.

Case managers with their small caseloads.

They absolutely have a role and
they'll be supporting the patients

that need to be supported that way.

but frankly, primary care is not
designed to support those patients

without secondary care supports.

So this comes back to
the coordination piece.

It does include some elements
of case management, such as

Kacey: More frequent touch points.

Morgan: That was Casey and RN
working with us at the ISU.

Kacey: So, again, when we look at how
much doctors are working, how long

hours are those pieces, is there's not
necessarily a lot of time left for more

frequent touch points, more frequent
opportunities to connect with people.

And when people are living at home
with frailty, there's A nurse can

be that person that just picks up
the phone maybe once a week and

touches base to say, Hey, Mrs.

Robinson, how are you feeling today?

Morgan: This kind of coordination doesn't
have to involve home visits, but it can.

If a nurse is joining your primary
care practice and you're interested

in establishing some, uh, Enhance
care coordination, who should get

that extra care coordination as I
asked that question, and if you're a

primary care provider, you probably
are already thinking of a few

people in your practice with complex
care needs that would benefit.

Those are the ones that
you're worrying about.

that may be not as well
connected to, either you or

other services like home care.

Those are the ones that you want to
have come in a bit, just a bit more

often, so you can check on them.

I imagine you already know who
those patients are for you.

Those are the patients.

And I think that we in primary care can
give those patients that lighter touch,

that consistent care coordination too.

And that's where a nurse could
start to meet them understand

and get to know them better.

There's clear benefits to
incorporating care coordination

into primary care nursing.

I think this is a place where a
nurse is able to do some clinical

assessments and recommend supports
and then coordinate changes to care

and those supports over the long term.

This benefits our patients
and their families directly.

This will reduce future avoidable crisis
visits in the clinic, particularly when

there are wait lists for higher level of
care, as there are in most communities.

Care coordination can also reduce ER
visits, particularly for things that are

ambulatory care sensitive conditions.

And this will help people
remain at home longer.

So that's the main idea for this episode,
thinking about care coordination for

select patients with higher needs.

So if a nurse is joining your practice,
and you have a few frail patients

that you're worried about, or other
patients that you're worried about

with complex needs, start there.

Plan to connect with those patients
and do a shared visit with the nurse.

Explain that you and the nurse would
like to work through an assessment

together and see how else we, your
care team, can better help you Stay

healthy at home, put together a bit of
a care plan and start working together.

And as you do, you'll of course, adapt
that plan and the nurse will inform

you and together you will adjust.

And as you go along, if this is
working for you, you'll think of

other patients that will benefit.

So that seems like a good
place to wrap up this team bit.

Thank you for listening to team up.

And if you have any questions
or topic suggestions, please

email us at isu at familymed.

ubc.

ca.

Sarah: The Innovation Support Unit is
a distributed multidisciplinary team.

We work mostly remotely from communities
across the Lower Mainland and

Vancouver Island in British Columbia.

Morgan: Sarah and I are both recording
from our offices in the territories

of the Lekwungen speaking peoples, the
Songhees and Esquimalt First Nations.

Sarah: And recognizing the colonial
history and the ongoing impacts of

colonization and healthcare systems
and in Indigenous communities in

Canada and around the world, as we
move through the season, we'll work

to bring an equity lens to this work.

And we really encourage you, our
listener, to reflect on your past,

present, and future participation.

On the indigenous lands
where you are situated.

Morgan: we'll see you in
the next episode of team up.