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Care Coordinators Offer Extra Support for Patients

By Meg Smith, RN, BSN, RNQCC | Manager COPA Care Coordination Team

Sometimes in caring for a child a family is faced with needs that go beyond the medical visit. This may include children with chronic illnesses, behavioral struggles, and families who are financially vulnerable.

Because the care of the child can be dependent on them getting to their appointments, connecting with the appropriate specialist, and following through with the doctor’s recommendations, COPA has created a Pediatric Care Coordination Team (CC Team), for which I’m responsible.

COPA’s CC Team including four experienced coordinators who set up the multiple medical appointments, lab work, imaging, therapies, and follow up care. Team members work closely with the family and their Pediatricians to assess their needs and understand specific challenges to getting treatment, including reaching out to community partners, non-profits, agencies, government and city services. From there they connect the family with the appropriate services.

We also care for families who are homeless or financially challenged and are needing extra support. The COPA CC Team refers them to resources where they can receive food and other basic needs.

One of the ways we serve these families is by networking with other pediatric RN care coordinators in the community who have similar challenges, allowing us to bounce around ideas for better ways to deliver care to all our patients and families throughout the region.  We frequently work with Deschutes County Public Health, which offers “CaCoon Nurses” (CAreCOordinationON), a statewide home visiting program for infants, children and youth with special needs. By working with healthcare partners in the community, children throughout Central Oregon have less barriers and greater access to the services available to support their families.

In my experience, COPA is providing a service that’s not typical for a pediatric clinic in a community like Bend. Usually, we will see this kind of care coordination in a metro hospital environment, which is my background. While these services are not reimbursed by insurance plans, they are necessary to keep our patients healthy, which is why COPA has made this commitment.

I think of one particular example that truly shows my team’s dedication to our COPA kiddos. We recently worked with a child who needed to get to Portland for care. However, the patient has a special condition that doesn’t allow him to leave his home. One of our team members worked all day on a Friday and into the night contacting numerous agencies and non-profits to find transportation for the child first thing Monday. She finally found a person in the community who was willing to transport the child under conditions that enabled him to travel. We were thrilled we could meet the family’s needs so that the child could be care for by specialists in Portland.

After years of building the program at COPA, our care coordination team is fully integrated with our medical staff to make sure that patients and families get all the care they need regardless of how complex. We go home each day knowing our work has made a positive difference in the life of a child and their family right here in our hometown.

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