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Spotlight on Care Coordination

​Care coordination is at the core of the North East CCAC's mandate. As registered health professionals, our Care Coordinators help individuals of all ages who have been referred for service to access the home and community care resources available in their communities. In the North East, the vast majority of our Care Coordinators are nurses who use their medical expertise to determine each patient's care needs and coordinate an individualized plan of care to restore/maintain health or ensure safety and independence at home or in school. Working closely with families and caregivers, and establishing strong liaisons with community health partners like family health teams, hospitals, long-term care homes and a myriad of community support services, Care Coordinators wear a number of different hats – counsellor, nurse, teacher, advocate – but they perform all roles with true compassion.

LisaTurpin.jpgLisa Turpin is one of only a handful of nurses at the North East CCAC with specialized training in palliative care. Her expertise allows her to understand the specific needs of a patient for whom dying with dignity is part of the care plan. "Often we need to help our patients accept what is going on before we can even create a care plan. We also work closely with family members who need our help and support, even if the patient isn't quite ready to accept services."

Lisa is so passionate about her specialized role that she felt compelled to write a Letter to the Editor that outlined the diverse tasks that a Care Coordinator can do in a day. "There is an element of social work to Care Coordination. We often serve as a facilitator for communication around a very difficult topic, getting patients and caregivers/families to talk to each other about the realities they are facing and to ensure everyone is on the same page. What are the patient's wishes? Where do they want to die? When is it time to set up a Do Not Resuscitate (DNR) order? As you can imagine, these can be very intense conversations."

During her 15+ years as a Palliative Care Coordinator, Lisa says that educating her patients has become an important factor in the process. "I've learned to educate and then take a step back to allow people to process the information and ask questions. Every palliative patient is an individual who is on their own unique journey."

Care Coordination is strongly based on teamwork, and just as building trust with the patient and family is important, it is also critical within the care team. Lisa says she relies on relationships with other service providers in the home to not only provide care, but to be her 'eyes and ears' to report on a patient's health status, and to get additional services in quickly if there is a sudden crisis.

"I work closely with the staff at the hospice, with the Palliative Nurse Practitioners who will go into the home and help deal with equipment or medication issues, with physicians who assist with pain control so patients are comfortable, and with Community Support organizations like Warm Hearts, among others. By bringing all of the available resources together, we provide the best care we can and help people live the time they have left with dignity – that's what it's all about."