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Care Coordinator Solves Communication Problem

Donna Young

Children’s Hospital Home Care (CHHC) in Denver was having a communication problem among its multidisciplinary patient care providers.

Former Pharmacy Director Paul Limberis said team members were providing good care. But because of a lack of coordinated communication, patient care wasn’t as effective as it could be, he said.

The home health company hired a consultant that helped the care providers identify the causes of the communication problems.

Limberis, now the senior pharmacy manager for the Denver office of USOncology, said CHHC team members developed a system that coordinates information about a patient’s care through one provider, called a care coordinator.

The care coordinator is responsible for implementing and documenting the patient’s care plan, he said. Care providers telephone the care coordinator with updates during the week. The team meets weekly to discuss the patient’s care.

"The care coordinator can be a person from any of the disciplines," Limberis said. "It depends on the patient’s primary therapy and who is going to be with the patient the longest."

For instance, most patients who need long-term total parenteral nutrition require a lot of care from a nurse, a dietitian, and a pharmacist throughout the therapy. In these cases, he said, the pharmacist would have the most contact with the patient, so the pharmacist would be the care coordinator.

A patient who needs two weeks of intravenous therapy at home also depends heavily on a pharmacist. But, Limberis said, in most of these cases the nurse spends more time with the patient than the pharmacist does. Therefore, the nurse would be the care coordinator, he said.

The home health company also designed a new documentation tool, or multidisciplinary care plan, that helps the team to better monitor the patient’s problems or progress.

Limberis said his former employer plans to automate the documentation tool so care providers can enter information on-site from laptop computers during home care visits.