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Care Coordination

Care Coordination and Workforce Development 

The patient navigator (PN) functions as the hub of the Zufall coordinated program. This person identifies patients served by the behavioral health program who need primary care services and facilitates scheduling for chronic conditions, medication refills, referrals and acute care visits. The position also serves as a conduit for communications between clinicians at Zufall and at Saint Clare’s regarding mutual patients.

Since the health records are not integrated, a form was developed to communicate between the programs. In addition, the PN arranges for phone calls or written communication between clinicians for specific issues.

For the past year, Zufall has “co-located” primary care providers at Saint Clare’s behavioral health sites via a mobile medical van that parks in front of the behavioral health center to provide physicals, screenings and routine follow-up to patients. This has greatly increased access to behavioral health patients who would otherwise have to travel to the health center for routine issues.

The PN has collocated in the behavioral health site for many years, and is a trusted member of the behavioral health team. The PN is part of Zufall’s behavioral health team, a member of the QAPI Committee and attends clinical staff meetings. The team is included in management and care of patients with comorbid conditions.

Zufall’s workforce development strategy includes:

  • Careful selection of applicants
  • Loan forgiveness for provider post-graduate education
  • Flexibility in scheduling and hours
  • Identifying areas of interest to engage providers in their community
  • Clean, modern facilities and workspaces
  • User-friendly EHR
  • Extensive staff support such as medical assistants who help with translation, documentation, tracking and follow-up of patients
  • Quarterly Grand Rounds at the site with CME credits offered
  • Frequent staff and clinical meetings to enhance communications and feeling of belonging
  • Scheduled training opportunities for different staff to further develop their knowledge and skills
  • Periodic activities that focus on topics like physician engagement and provider burn out

Leadership is committed to workforce development and retention and looks closely at pay and benefits to provide a balanced and competitive employment.

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