What is a care coordinator?

Navigating the healthcare system can be challenging for anyone. Now imagine adding the challenge of finding transportation to and from the doctor’s office, not speaking the same language and not having a translator available, the office not accepting your insurance, not having insurance at all, or having a disability and not having the proper accommodations available to enter the building; and also having to navigate your healthcare journey on your own. 

That is where our care coordination team comes in. Care coordinators partner with patients and their providers to connect patients with any outside specialists, and to help fill in any healthcare gaps for the patient. 

Healthcare gaps can look like a lot of things - including being overdue for an annual physical, patients needing to be seen for a follow-up and patients needing help finding an outside specialist that takes their insurance - to ensure patients are set up for success in following their care plan. Care coordinators also monitor and advocate for patients and their care plan. 

Marissa Sims, MSW has been an employee of Neighborhood since 2021. Coming from a social work background, she worked with individuals who were either living with or were at risk for HIV. At Neighborhood, Marissa is the supervisor for the Northwest and Riverway care coordination teams. She monitors the care coordination teams on the day-to-day of patient referral and imaging order management. She explains that care coordinators are part of Neighborhood providers’ care team assignments. Each care coordinator is assigned to specific providers, and are responsible for the care coordination of those providers’ patients. This can look like assisting the patient or families in fulfilling a referral from their provider and helping them connect with that specialists’ office. 

“For many of our patients, English is not their first language,” explains Marissa. “So, there is a little bit more that goes into helping them get connected with a specialist in the area.”

Marissa explains this is due to many specialist offices not having translators available. When Marissa connects with a non-English speaking patient by phone call, she has access to Neighborhood’s language line. With the patient’s permission, providers, care coordinators and other employees as needed can loop in a HIPAA-compliant interpreter to help connect with the patient. A lot of times, connecting a non-English speaking patient to a specialist is the care coordinator calling the specialist’s office and scheduling an appointment for the patient. 

All of the care coordination that Marissa and her teams provide is patient-centered. Meaning that if a specialist office seems not accessible to the individual or family they are working with, they will work to find a better option. 

“We don’t want [patients] to show up somewhere and they have a bad experience, or are not able to be seen,” said Marissa.

Marissa shares that a significant aspect of care coordination at Neighborhood is about meeting patients where they are at, and having understanding for differing levels of access to care and to health literacy, from patient to patient. Extending health literacy in the role of a care coordinator can look like preparing patients for a no-show fee at outside offices, explaining the importance of certain parts of their care plan, and exploring and comparing benefits so that the patient has autonomy in their care plan.

“Health literacy is a really big thing that I cannot stress enough for our patient population,” said Marissa. “Here at Neighborhood, we do really well with making sure healthcare is accessible and affordable, but it is not always like that at outside offices that we have to refer patients out to.”

In leading with patient-centered care, Neighborhood works to actively acknowledge that patients have a lot going on in their lives. Marissa makes reference to the “cup” analogy, which explains how an individual’s cup might be too full with other things to worry about in their life, that they might not have the capacity to manage their health on their own. For patient D., and many other patients at Neighborhood, having someone that is looking out for them and keeping them accountable to their care plan and health goals has been life-changing. 

“We come here and we want to make a difference,” said Marissa. “Being able to see the outcomes of that in our patients’ lives is really impactful for me.”

Quality Impact

In helping to facilitate any clinical needs patients may have following their visit with a provider, the work of the care coordinators contributes greatly to Neighborhood being rated the top health center for quality in WNY. 

“When working on a referral, our job then is to not just schedule that referral but to look at the patient’s care as a whole,” explains Casey Macleod, Neighborhood’s quality manager. “It’s making sure that follow up appointments are being scheduled, making sure they are up to date with all of their cancer screenings, having the conversation around the importance of those cancer screenings…whether it’s language-based, income-based, or health literacy-based, we are able to provide support in a number of different areas.”

Provider Perspective

“From a provider standpoint, having a care coordinator update me and provide resources for my patients in getting specialist care or imaging they need, it really helps us all to progress on the patient’s health journey,” said Arjun Bahattarai, MMSc, MPH, PA-C. “Care coordinators can really bridge that gap.”

Prior to coming to Neighborhood, Arjun was a care coordinator himself. He found the impact the role had on him, in addition to other experiences in his life, really pushed him to become a physician assistant. He also authentically shared the tougher side of the role. 

“If you dig deeper, there is burnout and frustration in [the care coordinator] role,” explained Arjun. “But the joy afterwards…knowing that you are seeing patients for the whole person they are, treating them with respect...personally, those are my values.”

Recently, Marissa was able to see the impact of her and her team’s work. Back in December, Neighborhood’s community health department coordinated a ‘Year End Giving’. This was a way for Neighborhood ambassadors to give back to the patients they serve. In coordinating patient care, Marissa has come to learn many patients, including patient D.’s unique stories. In this instance, a provider had nominated a patient whose family she had worked with in the past. Marissa had the opportunity to call the patient and tell her that she had been nominated. 

“For her, it was very monumental that someone had thought of her and that she was able to provide a couple gifts for her son for Christmas,” said Marissa. “It really touched my heart…that she felt seen and supported by us.”