Barbara Tofani Explains the Understanding Needed to Set Up a Care Coordination Model

When creating a care coordination model, it is important to understand what the model is trying to achieve and what everyone’s roles are in the model, explained Barbara Tofani, RN, MSN, NEA-BC, administrative director of the Hunterdon Regional Cancer Center.

When setting up care coordination teams, what is the education process?
There’s a lot of different models for care coordination. There are models where you have advanced practice professionals—so professionals with Master’s or higher degrees—there are models that you have nurse navigators or nurse coordinators, you have lay coordinators. I don’t know that the formal education preparation matters as much as what is the goal of your care coordination program. And having the right people and the right resources.

If you just say to somebody, “We want you to coordinate cancer care. We want you to be a cancer care coordinator.” And you haven’t identified what the goals are, you can find that people will be floundering, because you can do in a thousand different directions. The model in my organization, initially, was a business model of care coordination. We wanted to make sure that the community cancer center, we felt very strongly that patients are well served getting their care in a community cancer center. So, we wanted to use our care coordinators to help patients get into our system for the care and services that we knew we could provide and provide to the highest level of quality that would be expected of us. And then, for care and services that we did not provide within our organization, help patients get to those tertiary and quaternary facilities to get that care, and then come back to the community.

Because life doesn’t stop just because somebody has cancer. They’re still getting kids off the bus, they’re still working—many of the patients have to work, because their insurance is tied in with their employment. Many, many patients are sandwiched between their parents and their children, so they are caregivers for both ends of the spectrum. None of the stops just because they’ve been diagnosed with a cancer. They have incredibly busy lives and now we’re asking them to shoehorn in chemotherapy and radiation and surgery and then the issues related to fatigue and anxiety and depression and all the other things that go along with a diagnosis of cancer and the treatment of cancer.

So, I think you really have to educate your care coordinators: what is the goal of your program? What is it that we’re looking to achieve? Is it a business model? Is it purely a quality model? Is it an access-to-care model? What is it? And I think everybody has to be clear—I’ll use that same-size-fits-all—you can’t have 1 care coordinator do everything. They have to be very clear as to what is their role, what are the expectations, what are they trying to achieve?
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