Heather Akins has been coordinating care for patients for almost two decades—and has been working as a registered nurse for even longer. Her background as a traveling emergency room nurse and then as a home health and hospice nurse leveraged her expertise in a range of settings—from rural hospital ERs to the patient’s kitchen table.
About two years ago, she left a nursing leadership role to put all that experience to work as a care coordinator for Rocky Mountain Health Plans’ Medicaid members living in Larimer County. The Wellington resident works with a team of about 10 care coordinators to help residents living across more than 2,600+ square miles of farmland, foothills and mountains.
“There’s a lot of flexibility in this role that allows you to go that extra mile and help make a concrete difference in people’s lives. And that’s very rewarding,” Heather says.
A typical day includes calling clients who have been discharged from the hospital and emergency room, as well as managing a group of clients with identified care coordination needs. As one of only two RNs on the team, Heather says she enjoys taking clients who are dually diagnosed with both physical and behavioral health challenges. “I live off my Outlook calendar,” Heather says, noting her day is filled with appointments with clients. She visits patients in their homes and attends appointments with them when they see providers.
“So many of my clients struggle with memory issues, and that ability to express and prioritize their needs when they see a physician,” she says. “I talk to the patient prior to the appointment to hear their goals for the visit, then call and remind them about appointments the day before, and sometimes call them again to let them know the taxi is coming. Then I meet them at the appointment, take notes and help guide the discussion, if needed. You want the patient to speak for themselves, but you also want to make sure they feel like their new concerns are addressed .”
After a provider encounter, Heather helps patients follow up with new appointments or tests, or to follow through on what’s needed to advance in their care. Care coordination also means communicating with multiple providers who are working with a particular patient.
“At the end of the day, it’s about patients and what we can do to help them. Care coordinators can play such a vital role for members,” she says. “I hope the medical community will embrace our role and utilize us even more. Sometimes in health care, everything is so siloed. Our job is to help bridge those silos.”
Heather finds resources for patients so they can be successful in their care. That can be a challenge when resources are scarce. For example, the county’s inpatient alcohol and substance abuse treatment center is only able to provide up to three days’ care, which isn’t long enough for most patients with substance use disorder to get long-term results. “And without treatment, the cycle just continues,” she says.
Many patients are also homeless, and there is little local affordable housing available. Without secure housing, patients are at greater risk of losing their possessions, including legal documents and identification. Heather and her team work with patients to help. “The Murphy Center for Hope (in Fort Collins) is a great resource for many of our members to help them get through those processes, because it can be overwhelming when you don’t even know where to start.”
“People just want to know that somebody really cares about them,” she adds. “A lot of times our members are herded through lines or given numbers and told to call here or go online there. But many don’t have access to the internet. They just get frustrated and want to give up. I think we’ve been really successful when patients know we are willing to meet them face to face and have some personal interaction with them. and help them through the steps needed to meet their goals. that helps.”