The Collaborative Patient Care Management model relies on the nursing role of Patient Care Coordinator, an experienced RN with a BSN or MSN.
The twelve Patient Care Coordinators are responsible for leading patient rounds with an interdisciplinary team, developing an interdisciplinary care plan, and coordinating both inpatient and outpatient education specific to the needs and wants of patients and families. The PCCs are responsible for patient case management and discharge planning.
Patient Care Coordinators have no direct responsibility for other nurses; instead, they serve as experts and mentors to the entire acute care nursing staff. PCCs report to two CPCM Co-Managers, who foster collaboration and sharing of evidence-based best practices across the group practices.
The Patient Care Coordinators and physicians co-chair multidisciplinary practice groups in Cardiovascular, Diabetes, Neurosciences, Orthopedics, Pulmonary, Vascular, Women’s Care, and Hospitalist/Medicine.
The eight group practices consist of a multidisciplinary team of physicians, nurses, other clinical professionals, and allied health personnel. The team often includes staff members from social work and pastoral care. The practice groups span the continuum of care from acute inpatient care to outpatient clinics and physician offices. And each multidisciplinary team collaboratively defines standards of care, practice, and activities for the group’s patient population.
Each group practice meets at least 6 times a year to address clinical quality, outcomes, financial outcomes, and key customer issues including policies and procedures, marketing strategies, and evidence-based research. The meetings focus on quality, cost and process. Any member of a group practice team can bring an agenda item. Meeting notes are posted on the Internet for all health system employees to access.
Each multidisciplinary group practice receives a team-based scorecard that tracks performance outcomes aligned with organizational goals of quality, people, access, innovation, and value. In addition, each practice is evaluated on the team’s implementation of improvements in clinical care delivery. Action plans are developed and monitored when goals are not achieved.
Nurse-initiated patient education that promotes health maintenance is a cornerstone of the model. PCCs are responsible for planning and coordinating patient education, including outpatient group education. The PCCs often work with community health advocates to provide patient education in the outpatient setting. In addition, PCCs collaborate with social workers to educate patients, both in the hospital and after they have been discharged.