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Care Coordinators: Helping Patients Transition to Community Care

Often, care coordinators come into patients’ lives at a difficult time. By the time your assigned to somebody, she’s probably had a lot of experience with the health care system. And it’s likely that some of it has left her frustrated.

During transitions from hospital to home, these emotions can be especially strong. The triage process can leave patients feeling confused and alone. It’s to be expected that sometimes, when you walk into a new house, the patient you find there is going to vent.

Of course, it’s how you handle these expressions of frustration that matters. It goes without saying that as care coordinator, you have a well-developed set of communication skills. But on a gruelling day, even the most compassionate professional can use some reminders.

In this post, we’ll look at some of the actions care coordinators can take to minimize patient frustration during transitions.

What patients go through

If you’re a care coordinator, you know how hard it can be for complex patients once they’re sent home. When a patient is discharged, she may expect her health care journey to be laid out for her.

Of course, this just isn’t how the health care system works. Part of the reason is that Ontario is focused on patient-centred care. While this is undoubtedly good, it means there are limits to what you as a care coordinator can do before you get to know a patient.

As you’re aware, there are several steps that may occur before this happens. After referral to a Health Link, the triage process kicks in. Depending on a patient’s priority level, you may not be able to call her until two weeks after she’s sent home. That’s a long time for her to wonder what’s going to happen.

Not only that, but a whole lot can happen during this timespan. Severe anxiety can develop. Depression can set in or worsen. Some patients will experience serious health events that result in readmission to the hospital.

Needless to say, Ontario’s health care professionals are doing the best that they can. Initiatives like Health Links have been set up precisely because, when it comes to coordinating home care, improvement is needed.

That said, resources aren’t unlimited. And unfortunately, patient expectations don’t always reflect reality. But that doesn’t mean their expectations are unreasonable. And you almost certainly wish you could do more to help.

Consider this: according to a 2012 Canadian study, patients with unmet or partially met home care needs report higher levels of stress and negative feelings. As just one example, those who fall into this category were 62% experienced loneliness, as opposed to 31% of those who had their needs met.

The difficulty for care coordinators

Care coordination can be incredibly challenging. There are the hectic days. The demands from management. The often-insufficient communication with staff and outside providers. And the constant pressure to do more.

Still, for most care coordinators, few things are more difficult than dealing with patients in need. What could be more heart wrenching than fielding calls from people who are waiting for help to take a shower? There’s no doubt that your job requires a lot of strength—and a lot of compassion.

During times of transition, things can be especially hard. Most of the time, complex patients who have been discharged from acute care have been through a lot. In addition to physical pain and suffering, many have experienced significant emotional and psychological distress.

Being sent home without a clear set of next steps can exacerbate negative feelings, including helplessness and confusion. Sometimes these feelings are directed toward the health care system. As initial points of access for patients connecting to home care services, care coordinators often bear the brunt of this frustration.

When you first meet a patient who’s experienced distress and has spent time waiting for care, how does she react to your presence? Understandably, she may use you as a sounding board—and she may not always be calm. Most likely, you carry a lot of emotional weight after these interactions.

Needless to say, this isn’t the only stressful part of your job.

In 2015 and 2016, almost 40 million hours of publicly-funded home care were delivered in Ontario. And research suggests that the demand is far surpassing the care that’s available. The emotional and psychological challenges involved in care coordination are greatly compounded by the knowledge that there are so many patients out there who are in need.

The Power of Compassion

Many complex home care patients require rigorous emotional and psychosocial support. Often, this type of aid is most critical during the transition from acute care to home. Patients go from having support on demand to (in many cases) wondering when they’ll next speak to someone who can help.

Loneliness is an epidemic. Research also suggests that the feeling of being a burden can have a significant impact on wellbeing. For those who are often confined to their homes due to physical illness, the risk of experiencing these feelings is especially high.

A lot has been written about how psychologists and social workers can help. But care coordinators fill a relatively new position. As a result, there’s been less exploration into the role you can play in helping patients work through these emotions.

Of course, a big part of your job is connecting patients to the services they need—including those related to mental health. But you can’t do that until you understand them well enough to decide what patient-centred care means in their particular situations. And it can take time to work through the initial negative feelings to get to that stage.

To start with, employ the principles of good communication. It goes without saying that empathy is key—even in challenging situations. When patients become angry, frustrated, or defensive, t’s best to listen.

Trying to justify reasons for administrative difficulties may cause further upset. So remain calm. And when it makes sense to do so, validate the patient’s feelings. The words, “I can understand why you’re upset” or “that must very frustrating” can go a long way.

Once you’ve begun to establish a connection, keep it going by being there for the patient. It goes without saying that care coordinators need to check in with patients regularly. When you can’t be there in person, try harnessing the power of communication technology. Mobile apps allow care coordinators to have convenient face-to-face interactions with at-home patients.

There are many ways to connect with patients who are making the difficult transition from acute care to home. But in all situations, try to remember to let compassion be your guide.

A difficult—but rewarding—job

There’s no shortage of online forums for family caregivers dealing with emotional burnout and frustration. In most cases, these individuals haven’t received appropriate training to deal with their feelings. But all too often, we forget that professionals deal with many of the same emotional challenges.

As a care coordinator, it’s important to process these feelings so that you can stay calm in the moment. Especially when you feel provoked, remember to take time to put yourself in the patient’s shoes. The satisfaction you feel when you’re able to connect will be your well-deserved reward.

Feature image courtesy of Joel Kramer

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