CARE COORDINATORS AT YOUR SIDE
A team of nurse advocates empowers at-risk patients to live their healthiest lives
Can you afford food, rent and electricity? Are you
exercising? There are also questions about abuse, anxiety,
depression, and social connections.
Q: WHAT FORMS OF SUPPORT DO YOU OFFER
A: We ensure that they are educated about their medication,
have all their medication refills and that they’re
following up on testing. If they have any questions about
their care, we fill in the blanks. If a patient is upset, then
I just listen. They might tell me something that they’re
reluctant to tell the physician because they’re embarrassed.
We also arrange transportation to appointments. We
make sure that they have proper care at home. We try to
get homeless patients into shelters or provide them with
resources for apartments. We connect patients with community
resources and make sure we’re following up with
them after their hospital stay.
Q: CAN YOU GIVE AN EXAMPLE OF HOW YOU
HELPED A PATIENT IN A UNIQUE SITUATION?
A: Navigating with insurance companies can be confusing,
especially when you're feeling sick. I’ve been on
the phone for three hours with an insurance company
because a patient had questions. If they don’t know how
to apply for Medicaid, we tell them the steps. There’s a
lot that we do behind the scenes that many people don’t
know about. Anything that they need, we try to advocate
for. We’re trying to treat the person inside and out, not
just as a single diagnosis.
The Care Coordinator Program is available at three
physician offices in Winchester, two in Front Royal,
one in Strasburg, and one in Woodstock. The program
will expand throughout the Valley Health service region
Helping patients achieve their health goals includes more than just
direct patient care. Valley Health nurses known as care coordinators get
to know the whole patient—their medical records, medications, living
situations—to help identify challenges, offer solutions and reduce
avoidable hospital admissions. Patients are referred to them by the
physicians and are often on Medicare.
Desireah Burkholder, LPN, shares how the members of the Care
Coordinator Program help higher-risk patients—those with two or more
chronic conditions—get the support they need.
Q: HOW DO YOU IDENTIFY A PATIENT’S NEEDS?
A: Our goal is to help reduce hospitalizations and ER visits by increasing
communication between us and the patients. If the patient has had multiple
ER visits, that’s something we need to look at. We are their advocates. We
work hard for them.
We have a list of questions we ask: Can you afford your medications?
W I N T E R 2 0 2 3 7
Lisa Poster, RN, and
LPN, assist a patient.