1. Patient Care Coordinators Role in Diabetic Populations
NorthShore Health Centers
January 29, 2018

2. Patient Care Coordinator Role
Implemented Patient Care Coordinator program beginning in June 2016
“The Patient Care Coordinator is responsible for facilitating patient care services while aligning with Patient-Centered Medical Home (PCMH). The ultimate goal of the position is to improve access to care, quality of care, and patient outcomes through the self-care process.”
AADE Diabetes Paraprofessional Course

3. Target Populations Diabetic Population New Diabetics
Diabetics Referred by Provider
Diabetic Patients with an HbA1c > 9
ER Utilizers
Diabetics
Hypertension
Uninsured/Homeless and Depression
Referrals from Care Team

4. Patient Care Coordinator Process
In collaboration with the care team, assess and manage the health needs of the patient
Follow up with patients in the program to address their needs, continuously updating personalized health plans and engaging and empowering patients

5. Outcomes and Next Steps
Quality Team and Patient Care Coordinators collaboration
Continuous follow-up with patients
Next Steps:
Improving documentation
Widening population