Interview with CCM/BHI Care Coach (Leanna Reilly RN)

Leanna Reilly RNCare Coaches are the key to Medicare’s Chronic Care Management (CCM) and Behavioral Health Integration programs, providing the non-face-to-face follow-ups and coaching to manage chronic/mental conditions when they matter, between regular office visits.  At CircleLink, we use 100% RNs with over 10 years of experience and focus on providing a best-in-class experience to these key partners. Care coaches are the true stars of CircleLink’s platform.

In that vein, today we’re showcasing what it’s like to be a CCM Care Coach in the words of one of our top care coach partners, Leanna Reilly RN. 

A day in the life of a CCM nurse

Leanna: I have to start by telling you that a day spent on the job as an RN Care Coach is wonderful. I don’t have to commute or travel every day; I don’t even have to go outside if the weather’s bad. I can stay home with my cats, one of whom is 16 and needs me home daily. 

Switching to this job has been a rewarding and welcome change for my family and myself. At first, I wondered if I could make a difference in patients’ lives simply by calling them. A year on I know the answer is a definitive “yes.” 

One of the best things about this job is flexibility. I have a set amount of hours that I work each day. Once I’m ready to go, I log in and let my Director of Operations and Community Manager know I’m ready to start my day. 

The first thing I do is check my callback tracker to see if any patients called while I was away. I start with those patients first – and if I can’t do that, I start on my scheduled activities and call whoever’s most appropriate first. 

The calls themselves are as diverse as the people I work with. Some patients are busy and don’t have much to say when I call. Others love to talk and discuss their families, pets, financials, and community concerns. 

After talking to the patient and making recommendations based on their care plan and current health, I make notes that I later forward to the practice if necessary. Once I’m done with that, we schedule our next call and I proceed with another patient. 

I keep working until I run out of calls or finish my list, whichever comes first. I then message my Director of Operations and check out for the day. 

How I became a care coach

I started my nursing career as a Registered Nurse in 2008, working in the ICU. That was an incredible learning experience that helped me become the nurse I am today. 

Specifically, nursing helped foster my passion for teaching patients about lifestyle choices that can help them. I realized that many of our ICU patients’ problems could have been prevented by better life decisions, and, wanted to make a difference in that area. 

After leaving the ICU I worked in Telemetry for a few months and saw many of the same issues there too. This eventually nudged me towards taking up a nursing job in the Wellness and Preventative Medicine industry. In this position, I traveled to organizations and corporations to provide onsite wellness screenings and vaccinations for employees. 

Doing this for a few years, I was able to see patients making lifestyle changes because the results they got from our screenings. The excitement they felt when telling me about the weight they lost and how much better they felt was very rewarding. 

While I loved my work in Telemetry, I could also tell I was starting to get tired from traveling so much. That’s how I ended up at CircleLink Health. 

To date, this has been my favorite job. It lets me use my nursing knowledge, communication skills, and love of helping people — all without having to leave the comfort of my home.

A particularly memorable case

One time, I was making a first-time call to a patient. When she answered, she was out of breath and sounded very scared. She couldn’t catch her breath and hadn’t dialed 911 for assistance, so I called emergency services on her behalf. 

While we were waiting for them to arrive, I talked to my patient and helped her stay calm. When I called her the next month, she was very appreciative and said she didn’t know what would have happened if I hadn’t called her that day. 

Most positive impact on patient health

I was once on call with a male patient and asked if he had any health concerns. As he was describing his symptoms, I got an eerie feeling that all of them were consistent with Congestive Heart Failure. 

Although the patient felt seeing his doctor would be a bother, since the last check-up had happened just 2 months prior, I ended up calling our office and speaking with a nurse for the patient’s doctor. They were able to get the patient in within an hour, and evaluated him before transferring him to a hospital for CHF treatment. 

The patient’s spouse later said she was scared to think about what would have happened if I hadn’t been on hand to help them. 

With new medication and a better understanding of the patient’s dietary restrictions, they were able to better his condition. That was very rewarding for me. 

Most challenging practice

The most challenging practice, for me, is one that isn’t making full use of my service. For example, a practice that only wants to receive notes from nurses in emergencies is, in my opinion, not getting the job done as well as it could. 

A quality practice should do everything it can to look after patients on a month-to-month basis. One aspect of this that’s especially important to me is there being another RN Care Coach I can speak with. Not having this limits what I can do, and is a big issue. 

Biggest remote care coaching challenge

My biggest challenge would have to be getting patients to understand and trust what I do. Getting the benefits across isn’t always easy, but I have noticed that two things help. 

First, encouraging patients to ask questions and answering them patiently. Second, practices that proactively notify patients about what’s going to happen beforehand can help a great deal. 

Sometimes, patients are so skeptical that they don’t believe I’m a real medical practitioner. Many think I’m a scammer or salesperson until I relay information they can trust. I welcome this process and encourage people to talk to me, and use this challenge to lay the foundation for a trusting nurse/patient relationship. 

– Leanna Reilly RN

If you’d like to learn more about CCM or see how we can help, great! We’re here for you. Please email or call 917-999-6560.