Tuesday, February 11, 2014

Coordinating Care for Patients

As I continue to explore how the patient-centered medical home benefits our patients, I’ve heard from practitioners who are on the front lines, working hand-in-hand with patients to effectively coordinate their care. The lack of coordination for those with chronic disease is the biggest problem with the U.S. healthcare system.

I heard from Vergie O’Garro, RN Care Manager at GBMC’s Texas Station and Owings Mills primary care practices, who has been a nurse for more than 20 years. She talks about how the care she delivers today is very different from the primary care of years ago.

Here, Vergie shares her perspectives as a healthcare provider on the patient-centered medical home model of care: 

“Before the medical home, some patients would get lost in the shuffle. For example, when patients were discharged from the hospital, we didn't have a good way to ensure they understood their condition and we didn't have a way to follow up with them to make sure they understood the plan and were following it. There’s so much information provided at discharge and many patients have trouble remembering everything they need to do for their health once they are out of the hospital. Now, however, we contact the patients and guide them in the transition from the hospital to home, help them find resources, help them understand their care plan, ensure they are receiving and taking their medications and just manage their care better overall.

As an RN Care Manager, when I have a patient discharged from the hospital, I call the patient once they are home, go through the list of medications they need to take and make sure they understand how to take the medications. Follow-up and creating a plan of care is important for long term management of a patient’s condition.”

What does it mean to coordinate care?

“I work closely with our care coordinators to provide patients with the resources they need to maintain their health and manage chronic conditions. Coordinating care not only means guiding a patient through a chronic health condition, but also helping patients find resources, financial or otherwise. For example, some patients need help finding transportation to and from doctor appointments. Our care coordinators work closely with patients to help them with things like this, which is another important part of coordination of care.”

Can you give an example of how you help manage a chronic disease like hypertension?

“As an RN care manager, if a physician refers a patient to me for hypertension, for example, I’ll look at factors like hereditary and other causes of the hypertension. Maybe it’s stress, so I’ll  find out about how the patient handles stress and help them manage it better. We’ll discuss things like diet and I’ll create a plan for modifying their diet to promote a healthier lifestyle. I’ll also talk to the patient about incorporating an exercise plan. It’s important that I really listen to the patient. I’ll let them tell me what their symptoms are and how we can manage the condition together. After we come up with a plan for managing their condition, I’ll call the patient on a monthly basis to make sure they are progressing in the care plan. This is a very comprehensive way to manage disease that also helps cuts back on hospital re-admissions.”

I thank the members of our healthcare team like Vergie for making the patient-centered medical home reach its potential as we generate our four aims of better health, and better care, at lower cost and with more joy for those providing the care. The patient-centered medical home is a fundamental building block of our transformation towards our vision of being the company where everyone, every time, gets the care that we want for our own loved ones.

Have you had experience working with a care manager? Has it helped you coordinate your care?


  1. Good timing on this blog. My sister came to the hospital with no PCP. She came due to pain and could not walk. She was here for about 2 weeks and was discharged to Genesis Powerback facility for rehab. She is confused on what will happen to her after discharge as no one has guided her through this transition specifically. The resident MD at Genesis has seen her but did not discuss the future. At this point, I want to help her. What is the best path to follow? Should a RN care manager have helped?

    1. Have you spoken to the social worker at the facility? Also have you chosen a PCP? GBMC has great providers in our primary care offices. The RN Care Manager and Coordinator works close with the PCP in the primary care setting to assist patients like your sister through that transitions of care.

    2. Thanks very much, Mary. I think that you should help your sister organize a meeting with the physician who is overseeing her care at the Rehab facility to discuss her plan. Your sister definitely would benefit from having a primary care physician and team to coordinate her care once she leaves the Rehab facility. I would be happy to help you find a patient-centered medical home for her if you email me at JChessare@gbmc.org.


Thank you for taking time to read "A Healthy Dialogue" and for commenting on the blog. Comments are an important part of the public dialogue and help facilitate conversation. All comments are reviewed before posting to ensure posts are not off-topic, do not violate patient confidentiality, and are civil. Differing opinions are welcome as long as the tone is respectful.