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Supporting COVID-19 patients

Care coordinators play a critical role in providing care to COVID-19 positive patients, both hospitalized and non-hospitalized. Two important responsibilities of these health professionals are:

  • Initial follow-up
  • Home monitoring

Care coordinators follow up with any patient discharged from the hospital to ensure a timely and safe transition of care to their home and arrange a follow-up visit with a primary care clinician, either in-person or virtually through telehealth. These patients often go home with oxygen therapy that requires special attention.

For the home-monitoring program, a clinician will write an order for a pulse oximeter, which will be delivered to the patient’s home, along with two daily questionnaires sent to the patient via MyChart. The patient consents to monitoring their own medical condition, incuding oxygen level, temperature, heart rate, respiratory effort and general well-being, and can request a call from a nurse at any time. Nurses monitor patients’ vital signs and subjective condition seven days a week, intervening as appropriate, and escalating to clinician visit or recommendation to go to the Emergency Department. Most patients with COVID-19 remain in the community. Their conditions can range from asymptomatic to very fragile, requiring frequent touch points with a nurse and clinician. The care coordinators’ work is performed in full collaboration with primary care clinicians and registered nurses in the primary care offices.

“During our time with these patients, we explain the positive result; review the need for isolation and self-care; and discuss conditions which warrant immediate medical follow up,” said Kathy McKiernan, RN, Care Coordination manager. “With the risk of spreading of COVID-19 so high within the household, much of the anxiety and need for education concerns family members, so our care extends beyond the immediate patient in many situations.”

“Our primary care clinicians work closely with the team of care coordinators to be sure that NEMG patients who have received a COVID-19 diagnosis, or have been in the hospital during this pandemic, receive the care they need,” said Karen Brown, MD, medical director for Primary Care. “We are very grateful for the extra expertise and touches that they are able to share with our patients during this unprecedented time.”