When Care Coordination Saves Lives

Last October, I started my first job out of residency at a community health center in Washington, D.C. At the onset, my new gig looked and felt just like my continuity clinic from residency at a community health center in Chicago. I eagerly began my practice, making almost no changes to my practice style beyond pretending to care about the Redskins instead of pretending to care about the Bears. I was at home.

In pursuit of the quadruple aim as well as achievement of the patient-centered medical home standards, my new site had recently invested significant resources in growing the role of care coordinators. I was relatively clueless about how to properly engage a care coordinator. As a family medicine resident, I had become co-dependent on my team nurse, so when care coordination emerged at my health center in Chicago, I feigned oblivion and continued to rely on “Super Nurse Shequieter” to keep me from imploding.

On a daily basis, my team care coordinators gently reminded me that the tasks they caught me doing at the fax machine were tasks with which they could assist me. That the referrals they saw me reviewing with patients were for appointments that they could help schedule. That the geriatric patient who got lost walking to the lab was someone whom they could escort.

“Oh, thank you so much for offering to do that,” I said, as I continued to try to be my own care coordinator for no good reason beyond inherent stubbornness.

Patricia Martin, D.O.

One afternoon, a care coordinator from a different team caught me between exam rooms. She looked stricken, her perpetual calm and easy smile both absent.

“I need you,” Retina said, waving me toward her. “I need you to come with me. Now.” I stopped what I was doing and followed her to her desk. There was a call on hold. A patient on the other line was following up with her provider’s team care coordinator because she had an issue with her referral. Or so she thought.

The patient was leaving her appointment for a dating ultrasound. According to the patient, she was advised by the sonographer that there was no pregnancy in the uterus. She would need to call her doctor to follow up and may need to have a new referral generated for a comprehensive pelvic ultrasound.

The patient called Renita to relay the message about needing a new referral, but for some reason, the patient didn’t sound like herself on the other end to Renita. She seemed distressed, so Renita trusted her instincts and found the nearest provider to help sort it out.

As I spoke to the patient, I realized her distress came from the lower abdominal pain that had developed that day. I advised her to go straight to the Emergency Room where her ectopic pregnancy was diagnosed. Thankfully, she had emergency surgery that afternoon and avoided a rupture of the ectopic pregnancy. I spoke to the patient later that night and saw her in the office a few days later. At that visit, her feelings about Renita were clear.

“She saved my life,” the patient said. I agreed whole-heartedly. In addition to the outstanding emergency department and surgical teams that treated our patient at the hospital, Renita played a pivotal role in saving that patient’s life.

Most of the time, care coordinators face the seeming unforgiving webs of hospital phone systems and medical records departments. They get hung-up on and chastised and ignored. They start the morning with a stack of paperwork that will undoubtedly replicate itself in 72 hours or less.

And yet, care coordinators remain present for our most vulnerable patients. They answer those important calls like the one that came to Renita, and sometimes, answering that call can make all the difference.

Patricia Martin, D.O., is a family physician at Unity Health Care – Minnesota Avenue Health Center in Washington, D.C. She is a graduate of Rowan University – School of Osteopathic Medicine in Stratford, NJ and the Family Medicine Residency Program at West Suburban Medical Center in Oak Park, IL. She currently practices full-scope family medicine with special focus on maternal child health.

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