The survey found that care coordinators need more support and resources to help patients. Nearly 70% rely on colleagues and 60% use personally collected materials for referrals. 98% want additional support like online referral resources and networking. Over half preferred online referral resources. The survey identified needs for improved training, current information, and abilities to understand learning styles and listen to patients. Care coordinators help with various needs including education, appointments, insurance, and translation. More support is needed for their important role in improving health outcomes.

1. Care Coordinator Needs Assessment Survey
A recent study conducted by The Center for Workforce Studies that Care Coordination is viewed
“by case study participants as a valuable tool to improve both individual and population health”
and “an important strategy to improve health outcomes because it provides patients with
appropriate access to health services and permits them to participate in improving their health
status and enjoy healthier lives.” With this important Care Coordination need in mind, Healthy
Capital District Initiative (HCDI)of Albany, NY seeks to identify ways to support Care Coordinators
in their profession to assist with better health outcomes for patients.
Survey participants
The survey was conducted by HCDI in summer, 2015 and participants included a variety of
nurses, special needs providers, care coordinators, community health workers, home care
providers and others. Ninety-five percent of the participants were from the Albany, NY capital
district area. Prior to the survey, primary information was gathered from local health
organization leadership, acting as key informants, with detailed qualitative interviews being
conducted.
Key Results
From the data, it was determined that nearly seventy percent of respondents indicated that they
have to rely on other professionals within their organization for informational and referral
resources needed to identity means for patient care support. Sixty percent of those surveyed
rely on materials that they had to personally collect in order to provide patient care support.
(Example 1) This could be an indication that many care providers and coordinators themselves
are in need of additional support from the community.
Results confirm that there is a clear need for support in that 98% of respondents chose some
form of additional support needed to help them be successful in their jobs. Of the 98% two-
thirds chose regional online information referral resources and local networking opportunities.
(Example 2) When asked about preferred means of obtaining referral resources, over half of
survey participants indicated online referral resources as a source and an additional one third
would prefer online forums. (Example 3)
Qualitative interviews also indicated that current training for care providers had some
deficiencies in that there was a “need to run the training for a longer period” or that “some sort
of repeat/refresh situation would be helpful.” It was also indicated that there is a need for “a
forum resource for continuous training/knowledge upkeep”. Interviews also disclosed
deficiencies found in many currently available resources were indicated to be a lack of current
data with “no real alerts to changes”.

2. Example 1
What informational and referral resources do you use to identity means for patient care support?
Answer Options Response Percent
Other professionals in my organization 67.6%
Personally collected material 59.5%
In house directory of regional referral sources 48.6%
Insurance providers 40.5%
Organizational protocol or procedures 45.9%
Professional organizations 43.2%
Health related webpages 37.8%
United Way 2-1-1 Northeast Region 18.9%
Please specify other referral guidance from local organizations. 10.8%
Empirical research journals 8.1%
Example 2
What other referral resource(s) would help you to be successful in your job?
Answer Options Response Percent
Regional online information & referral resources 33.3%
Local networking opportunities 33.3%
Local speaker series 16.7%
Regional list of training opportunities 11.1%
Regional online forums for sharing 2.8%
Other(s) (please specify) 2.8%

3. Example 3
Meeting the Needs
Survey data gathered provides a snapshot of services and support provided to chronically ill and
other patients in the Capital District area. Approximately,two thirds are providing patients with
health education and assistance with health insurance coverage. Half of those surveyed are
arranging appointments and behavior health needs; while many are assisting with language
barriers, transportation, nutrition and other critical needs. (Example 4)
Additional outreach to local care provider leadership indicated that Care Coordinators need
abilities in “identifying patient’s mode or style of learning (ex. Visual learners), ability to read
social ques and listen (very important) and to be non-judgmental; as patients can be intimidated.
The required level of critical thought skills needed for those in care coordination is elevated.
Example 4
What are the primary service needs that you are helping patients to secure?
Answer Options Response Percent
Health education 66.7%
Ensuring health Insurance coverage 61.1%
Arranging appointments 55.6%
Arranging social support services needed 52.8%
Arranging for behavior health needs 52.8%
Communication and translation for non-English speaking
patients
41.7%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Online referral
resources
Conferences Online Forums Webinars Other
How would you ideally access referralresources
that may be available to you?

4. Arranging transportation 38.9%
Arranging for nutritional needs 38.9%
Arranging for Physical or Occupational Therapy needs 36.1%
Counseling or training family caregivers 36.1%
Coordinating prescription/medicine needs 30.6%
Accompanying patient to appointments 22.2%
Ensuring emergency room follow up appointments 11.1%
Arranging for Hospice or Palliative Care 11.1%
Arranging patient legal counsel 8.3%
Preliminary Research
Care Coordination
Care coordination is the deliberate organization of patient care activities between two or more
participants (including the patient) involved in a patient’s care to facilitate the appropriate
delivery of health care services. Organizing care involves the marshaling of personnel and other
resources needed to carry out all required patient care activities, and is often managed by the
exchange of information among participants responsible for different aspects of care.
Services provided
 Establishing accountability and agreeing on responsibility
 Communicating/sharing knowledge
 Helping with transitions of care
 Assessing patient needs and goals
 Creating a proactive care plan
 Monitoring and follow up, including responding to changes in patients' needs
 Supporting patients' self-management goals
 Linking to community resources
 Working to align resources with patient and population needs
Care Management
Care Management is an emerging concept that refers to a set of evidence-based, integrated
clinical care activities that are tailored to the individual patient, and that ensure each patient has
his or her own coordinated plan of care and services.
Case management refers to the case (ie diagnosis) and how to best meet the guideline criteria
for this particular case, e.g., by involving case managers (most often: nurses or nurse
practitioners) who could steer the process;

5. Services provided
Coordination activities
 Making appointments
 Calling patients to check-up on them
 Helping arrange for services or connecting patients to community resources
 Finding a nursing home and getting the patient accepted to it
 Systematic assessment of the patient’s medical, functional, and psychosocial needs
 System-based approaches to ensure timely receipt of all recommended preventive care
services
 Medication reconciliation with review of adherence and potential interactions
 Oversight of patient self-management of medications.
Resources
1. The Center for Health Workforce Studies. Care Coordination Case Study Preliminary
Findings. N.p., Apr. 2014. Web. Aug. 2015.
2. Rieve, Julia A. “Asthma Case Management Outcomes.” The Case Manager. 26-27. Print
3. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume
7—Care Coordination. Publication No. 04(07)-0051-7, June 2007.
4. Agency for Healthcare Research and Quality, Rockville, MD. Available
at: http://www.ahrq.gov/clinic/tp/caregaptp.htm. Accessed October 17, 2012.