Care Coordination

Able to do Virtually

Some patients would benefit from a review, prior to seeing a specialist, to ensure all the appropriate investigations, etc. are completed and available at the specialist. This could avoid an unneeded cancellation of appointments.

RNs should be highly involved in collaborative care planning with patients, other members of interprofessional team and offsite partners/resources. Much of this work and the related coordination with other members of the patient’s circle of care can be completed virtually.

VIDEO MAY HELP: Video and group conferencing tools may be very helpful in collaborative care planning, particularly for complex patients and for transitions of care (e.g. to/from acute care)

Able to do Virtually

In primary care, RNs can focus on supporting patients with complex care needs in hospital by providing care coordination for discharge.

This would ensure follow up with the primary care team, appropriate planning, assessing availability and need for community resources/referrals, ensuring optimal utilization and evaluating effectiveness of current treatments (e.g. home oxygen, home safety, mental health, home care)

Able to do Virtually

RNs can focus on supporting patients and their families with complex care needs by providing care coordination and by working as a virtual navigator. In this way, RNs could be highly involved in collaborative care planning with patients, family members, other members of interprofessional team and with offsite partners/resources. This could include other community services, such as supportive housing teams, etc.

Much of this work and the related coordination with other members of the patient’s circle of care can be completed virtually.

VIDEO MAY HELP: Video and group conferencing tools may be very helpful in collaborative care planning, particularly for complex patients and for transitions of care (e.g. to/from acute care)

Able to do Virtually

In primary care, RNs can focus on supporting patients with complex care needs in community by providing care coordination within the primary care team. This would support continuity of care. This can include aspects of coordination of care plans and follow up but also, and perhaps more important, ensuring the team knows how the patient is doing overall and where needs may be that could be met, proactively, across the team. Much of this work and the related coordination with other members of the patient’s circle of care can be completed virtually.

VIDEO MAY HELP: Video and group conferencing tools may be very helpful in collaborative care planning, particularly for complex patients and for transitions of care (e.g. to/from acute care)