Northern Maine Medical Center’s Care Coordination program provides necessary assistance to patients in the Accountable Care Organization (ACO) to assure wellness, health management and better control of complex health issues, without discrimination of race, age group and dual eligibilities.
Care Coordinators reach out to ACO patients who have had an ER visit or have been hospitalized at Northern Maine Medical Center. While in the hospital, the “care team”, which is comprised of the patient’s primary RN, a social worker, hospitalist and RN Care Coordinator, will meet with the patient to discuss discharge planning and services that may be needed upon discharge. Some patients will transition to skilled rehabilitation, long term care facility or private home. The RN Care Coordinator during this meeting introduces the “care management process” to the patient. It is also be made clear that the “care management” service is optional and the patient may opt to agree or refuse this service.
Care Management: if patient agrees, this service starts within 1-2 business days of discharge. The RN Care Coordinator completes an admission flow sheet and develops a plan of care with the patient and/or caregiver involved in patient’s care. At the time of admission the RN Care Coordinator and patient will agree on frequency of calls and support of other outside agencies if necessary. During these phone calls the RN Care Coordinator will reconcile medications and update the patient’s Primary Care Provider and medical assistants on any changes if applicable.
ER visits: Within 24 hours of an ER discharge, an ER RN contacts the patient to assure the patient is doing well and understands their discharge instructions. The RN also verifies the date and time of the follow-up appointment with the Primary Care Provider (within 3 days of ER Discharge). The RN Care Coordinators then contact the patient within 2-3 business days after the ER visit. When calling the patient, the Care Coordinator will offer support and case management, making sure the patient understands that this service is optional and they may opt out at any time. Medications are reconciled and discharge instructions are reviewed with the patient to ensure compliance and understanding on the patient’s behalf. (This encounter can also be done in person if the Primary Care Provider office visit occurs within the 2-3 business days after discharge)
Northern Maine Medical Center’s Care Coordinators assess patient’s needs such as Emergency or Inpatient discharge follow-ups, Skilled Rehabilitation needs, Home Health Services, Hospice/Palliative Care or any other community services necessary. The objective is for the patient to regain optimal health, and in the case of Hospice/Palliative patients, the focus is to control pain and meet comfort needs.
Linda Russell, RN, is located at Acadia Internal Medicine office and can be reached at 207-728-6359
Stacy Raymond, RN, is located at the NMMC Medical Office Building, Internal Medicine Office, lower level and can be reached at 207-834-6784.