Have you ever gotten lost in the health care system?

Most likely, you have. And, if you weren’t the patient, you were probably helping a relative navigate through a maze of specialists, departments, medications and follow-ups. In fact, the problem of patients falling through the cracks in the system is so widespread and the consequences so serious, it is one of the hottest topics in health care today.

How we improve

As dire as that sounds, there’s good news: A lot is being done to better coordinate patient care and qualified help is on the way. But first, here’s why your frustrations are valid.

Let’s use this example: You’re helping your elderly aunt who has diabetes, a bad heart and suffering from pneumonia. After a hospital stay, this wonderful woman had to be rushed back a few days later. Based on recent studies, there is a good chance the situation could have been avoided if her care had been better coordinated.

“The patient as a passive participant is becoming a thing of the past.”

According to the Robert Wood Johnson Foundation, the main reason for high readmission rates in the U.S. is that discharged patients need more help than the system is currently providing.

Nurses as crucial ligament

Remember my initial question about getting lost in the system? I know because I lived that firsthand. Several years ago, my husband, Eric, suffered a stroke at O’Hare Airport just before boarding a plane. He was cared for by more than 50 health care professionals and students in Chicago, and dozens more when he returned to Philadelphia for rehabilitation.

Given my background as a registered nurse (RN), you may think this was easy for me to handle. It was not. We struggled to figure out transitions to the right setting after Eric left the hospital, to coordinate medical records and prescriptions and to deal with complex discharge instructions.

His case cried out for someone to take charge of his care, navigating between health professionals and health care systems and the places they intersect. Nurses are perfectly suited for this role. We are the boots-on-the-ground providers. We work directly with patients, every single day.

In addition, our education and skills make us the ideal partners to work with other health care professionals in many settings. Nurses are everywhere: schools, homes, long-term care facilities, community health centers and battlefields.

Providing training and partners

I’m not saying care coordination is a new idea; in fact, many health systems have individuals in this role, although the titles may vary. And, nurses themselves have been doing care coordination as part of their job for decades.

But until recently, there were few education programs and no board certification specifically for nurses in care coordination and transition management, also known as CCTM. What does this mean for you, the patient?

First, know this: The patient as a passive participant is becoming a thing of the past. For nurses, CCTM education means opportunity. In fact, the Affordable Care Act has focused new attention on the need for “patient navigators” and industry pressure for better outcomes from hospitals, including lower readmission rates, has intensified.

Not every case requires a coordinator, of course. It’s a role most needed for patients with complex and chronic conditions. But if you suspect that you or a family member needs one, ask for an RN care coordinator. They’re educated to do the job and will help get you safely through the maze, and back home where you belong.