Care 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 R., RN.

A day in the life of a CCM nurse

I have to start by telling you that a day spent on the job as an RN Care Coach is wonderful. Switching to this job has been a rewarding and welcome change for my family and myself. 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 family and cats, one of whom is 16 years old and needs me home throughout the day.

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 start my work day, I log in and let my Director of Operations and Community Manager know I’m ready.

The first thing I do is check my callback tracker to see if any patients called while I was away. I start by calling those patients first. Following that I start on my scheduled activities calling whoever’s most appropriate first based on my patient’s preferred call times.

The calls themselves are diverse and include people from all lifestyles. Some patients live alone, love to talk, and look forward to their call each month. I come to know not only their health concerns, but also about their family, pets, financial struggles, and community concerns. Other patients are busy and don’t have much to say when I call. However, they still appreciate knowing they’ll be checked in on each month and that we’re here if they need something.

After talking to the patient and making recommendations based on their care plan and current health, I note the patient’s progress and I forward that note and/or call the practice, if necessary. Once finished with the patient’s progress note I schedule his or her next call and proceed to call 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, it helped foster my passion for teaching patients about lifestyle choices that can help them. I realized that many of our ICU patients’ problems were preventable by better life decisions, and I 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 led me towards 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 of the results and coaching they got from our screenings. The excitement they had when telling me about the weight they had lost, the change in how they felt, and their lower risk for health complications was incredibly rewarding.

While I loved my work in the Wellness industry, I was tired of traveling and began looking for other options that would have me home more. 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 his doctor’s office and speaking with a nurse. We were able to collaborate to get the patient to the office 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 called them that day and she expressed gratitude for the service.

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

Most challenging practice

The most challenging practice is one that isn’t making full use of our service. For example, a practice that only wants to receive notes from nurses in emergencies is, in my opinion, missing out on many of the benefits of the CCM program. Also if the practice does not allow me as an RN Care Coach the ability to speak with or leave a message with the provider’s nurse this presents a challenge as well.

Biggest remote care coaching challenge

My biggest challenge would have to be getting patients to understand the service we provide and trust what I do and who I am. Getting the program details across isn’t always easy, but I have noticed that two things help.

First, I encourage patients to ask questions and I provide them simple, precise answers. Second, practices that proactively notify patients about what’s going to happen beforehand can help a great deal.

Sometimes, patients are very skeptical and do not want to speak with me regarding any of their information until they have spoken with their provider. I welcome this concern and encourage patients to verify the information I provide before we proceed with further calls. I have found that by acknowledging patient’s feelings and allowing them the chance to have their concerns addressed a solid foundation for a trusting nurse/patient relationship is developed.

– LeAnna R., 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) 746-2708.