Whether they're inpatient or outpatient, some patients need help sorting out all the services that might benefit them. That's where care coordinators come in.

They may be heath care professionals, such as nurses; they may be social workers; or they may be someone specially trained for the job. And with the rise in health care homes in Minnesota, there are bound to be more care coordinators, helping patients with chronic illnesses navigate their way to the best, most cost-effective care.

Part of a movement that began in 2007, health care homes were designed to improve care coordination for the most complex Medicaid patients. Now major health systems are adding primary care clinics to the ranks of health care homes to help complex and regular patients and reduce the cost of care.

How they help

Care coordinators are on the front lines of care navigation, and can be particularly helpful in pediatric settings. Holly Coy, RN, care coordinator in pediatrics at Park Nicollet's Minneapolis clinic (www.parknicollet.com), assists any family whose child is expected to have a health care need for more than a year. Conditions may include asthma, attention-deficit hyperactivity disorder, developmental delays, spina bifida or cerebral palsy.

Coy helps families find medical specialists, get school services and access community resources such as county caseworkers or social workers. Coy started as a hospital floor nurse, went on to do telephone triage and has been a care coordinator for three years.

"The families who don't really know what lies ahead don't know how I can help them," Coy explained. "The families who have been working through the system themselves, they're like, `Somebody to help? Thank you so much.'"

Inpatient care

Gillette Children's Specialty Healthcare (www.gillettechildrens.org) employs a team of job-sharing care coordinators in its inpatient rehabilitation unit. Their patients may have brain or spinal cord injuries; brain tumors; neurological deficits; strokes; or may be recovering from surgery. Jill Olson worked as an inpatient rehab nurse for five years before going to graduate school, marrying and having a child.

She job-shares with her mentor, Tessa Brandt, splitting the work week and talking each day about patients. "I just wanted to work really closely with these families during the daytime hours and it was a really good fit for me," Olson said. "We've had really positive feedback."

Olson and Brandt work with families and other health care facilities through the admissions process; facilitate rehab rounds, and run interference with insurance companies. "I tell the families I am a good go-to person," Olson said. "If you don't know where to go, come to us."