Patient Care Coordinator

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Patient Care Coordinator

Team Members and Sample Job Descriptions​​​​​

The care coordination position is designed to assist patients, parents/family members and caregivers with:

  • Referrals to specialists and other care providers
  • Communication between the child's primary care physician, service providers and subspecialty physicians
  • Support for parental concerns
  • Problem solving to promote the patients' well being

Additionally, the Patient Care Coordinators' work will serve to afford physicians more time in direct clinical care, and provide to patients a more direct portal of entry to having needs met.  In accordance with the principles of the Patient Centered Medical Home, care delivered by the care coordinator(s) should be accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective. ​

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​Job Respo​nsibilities

Broadly defined, the Patient Care Coordinator (PCC) will:

  1. Maintain the registry of children with special health care needs
  2. Pre-visit Planning (PVP) prior to children physicals
  3. Be available to assist with physician-directed quality improvement projects to improve various outcomes (eg asthma)
  4. Assist with and anticipate health care transition steps from adolescence to adulthood
  5. Improve communication between families, the practice, community services and health care providers

More specifically defined, the Patient Care Coordinator (PCC) role includes:

A) Registry Management:

  • Request to the physician for diagnoses, complexity score and need for PVP
  • Assist with down-regulating or up-regulating "need level" of registry families
  • Entry of complexity score in registry and update of diagnoses
  • Assurance of adequate time for visit
  • Develop assessment-based tools for who needs care coordination

B) Pre-Visit Planning:

  • Completion of PVP phone call to parent and team members if required
  • Completion of PVP log
  • Initiation of parent survey on the PVP value on a periodic basis
  • Gathering lab work results, discharge summaries, recent relevant physician correspondence, latest family concerns if known, for physician to review prior to visit

 C)  Quality Improvement Projects and Liaison with Community Health Team:

  • Be available to assist with physician directed improvement projects using the Children with Special Health Care Needs (CSHCN registry (improving Asthma care outcomes, for example)
  • Assist with development of protocols for care plan completion for group home patients
  • Meets with other Patient Care Coordinators (PCCs) within the network to support, train and liaison with community resources, cross-pollinate ideas and share experience
  • Identify children who need financial assistance and refer them to local agencies for help
  • Collate eligibility criteria for public health service
  • Share info with parents on appropriate diagnosis-based topics (support groups, studies, educational speakers)
  • Assist with parent education sessions
  • Assist with patient satisfaction surveys
  • Help physicians identify parents for parent-to-parent support opportunities
  • Continue to educate self and clinicians about local/state resources; encourage interface with various support agencies
  • Present Patient Care Coordinator (PCC) work at educational meetings on Medical Home
  • Maintain data base that tracks clients served, categories of activities and  time spent, for review and planning purposes
  • Create annual report of activities and complete an evaluation process for supervision/development, strategic planning, and quality improvement
  • Attend an annual pediatric state care coordinator meeting along with AAP chapter meeting

D)  Health Care Transition

 E)  Improving Family Communication/Continuity and Care Coordination:

  • Perform nurse screening role for registry patients for their visits, allowing for face to face clinical interactions whenever possible (institution of health maintenance check lists)
  • Interact with school nurses, health departments and other community agencies, including the Department of Health Access
  • Coordinate specialty referrals, which involves:
    • Arranging appointments if parent desires.
    • Assuring appropriate records are forwarded
    • Send appropriate chart records to specialist
    • Assure referral was completed
    • Access records of referral visit and direct referring physician
    • Maintain referral log
  • Coordinate procedure schedule and home care services
  • Communicate with parents/hospitals around hospitalizations and new diagnoses
  • Make daily call to hospitalized children/families
  • Communicate the status of hospitalized to the physician on call and enter note in patient's chart
  • Attend community meetings and Care Conferences
  • For patients with extended stays, greater than 1 week, make weekly calls to parents
  • Arrange follow-up care with hospitals; assure discharge summaries/data are available.
  • Take verbal reports on patients being discharged from hospital and direct info to physician who will see patient
  • Work to identify/integrate children who come only for episodic care; encourage PE's, immunization update, and developmental/lead/TB/anemia screening for such patients
  • Template and write letters authorizing service and equipment for patients
  • Help maintain printed or online directory of consultants
  • Log each PCC call to assist with continuity of care, and ultimately, billing for PCC
  • Develop and maintain parent email directory
  • Perform other duties related to Medical Home as assigned​

Preparation and Training:

Registered nurse with training in medical home and knowledge of current medical home, preferably with established connections with and knowledge of medical home families.  Must have appropriate training in business machines, spreadsheets, Medical Manager software, work processing and Windows computer skills.  Kind and assertive interactional skills, excellent listening skills and careful record-keeping are requisites for this position. Clinical knowledge of children's chronic medical condition and medical terminology are a definite asset for this position.


With the above preparation and training, it will take approximately 6-12 months to become proficient in the CC role, and in the policies and procedures of the practice. Experience with parents of CSHCN, and/or knowledge of local/state services would be a specific asset. ​

Independent ​Judgement and Professional Behavior:

While the care coordinator will have the general supervision of the primary care provider assigned to the family they are working with, personal judgment is essential to identify when to involve a physician.  Any questionable cases should be discussed with the physician most familiar with that patient, or his/her team member. Individuals who require the assistance of the care coordinator may be stressed by their child's condition, and will require a calm, professional approach to best help them. Because the CC will represent the practice to the greater community, tact, good manners and a cooperative attitude are mandatory.

​Working Conditions:

Most of the work is performed under usual working office conditions. The position has some exposure to communicable diseases by virtue of working with sick children.  The position requires the physical ability to obtain charts from medical records, and occasionally to lift children or push wheelchairs. Some travel between office and community based schools or services may be needed. ​

Mental Demand:

Duties require normal mental and visual attention with manual dexterity for data entry. Must be able to communicate by telephone, so normal or corrected hearing and vision are required.

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