In celebration of National Nurses Month, we’re highlighting a couple of our incredible in-market nurse liaisons who work within our Post Acute Care Site Optimization solution and the impact they have on members every day.
Meet Brandi, RN, Post Acute Care On-site Nurse Liaison
When Brandi was still attending high school, she had an unforgettable experience that changed her life. Driven by her passion for caring for others and eagerness to move beyond fast-food jobs, she explored the possibility of becoming a nurse’s aide at a nursing home.
Yet when the recruiter met her, she thought Brandi would be the perfect fit for another role as a companion to a 100-year-old woman who wanted to live out her final days with dignity in her home. Brandi immediately accepted the position and cared for the woman for nearly a year. When the woman was about to pass, she flew back from college to be with her during her final moments.
“I joined her family as we gathered around her bedside, but I was the biggest mess of them all,” she recalls. “I thought of this woman as my family too, and I loved being part of a moment where I could honor and support somebody during their weakest time. I never loved anything more.”
Brandi went on to become a nurse and worked in various roles throughout her career, until four years ago when she was recruited as an in-market nurse liaison for CareCentrix’s Post Acute Care Site Optimization program.
“I love this program because the members realize they have someone by their side to understand and advocate for their wants and needs, and remind them that they’re people, not just another number,” she explains. “They have a newfound trust in their insurance company when they see that we’re there on their behalf with the sole purpose of helping them.”
The Right Care, At the Right Time
Many payors that have internally managed post-acute care programs face challenges coordinating care between acute and post-acute settings. They may lack cross-functional integration, comprehensive analytics, and sufficient resources to address their members’ complex, multi-faceted needs. The result is often fragmented care, suboptimal outcomes, and increased costs.
50% of readmission spend is a result of members who are discharged home without the necessary care or support they need to recover.1
With CareCentrix’s Post Acute Care Site Optimization solution, nurse liaisons offer on-site and telephonic support, working with hospital case managers to optimize patient care. From there, they focus on building trusted relationships with members and their loved ones and supporting and advocating for them throughout their stays and transitions of care.
“Our nurses are with the members, learning why they were admitted, identifying the issues they have with managing their conditions, and addressing their fears about going home,” according to Farrah Spear, MSN, RN, director of CareCentrix’s nurse liaison program, who was first inspired to become a nurse when she was a young adult after watching the nurses who provided compassionate care for her mother as she battled colon cancer.
Through established relationships with hospital care teams, the nurse liaisons collaborate with clinicians and discharge planners to identify care pathways that optimize clinical outcomes and move members to the optimal post-acute care setting, whether that be the home or another facility. “We ensure the patients get the right care at the right time in the most cost-effective, appropriate setting,” Spear says.
With access to the hospital’s EMR and CareCentrix’s proprietary HomeFirst Analytics platform, nurse liaisons have transparency into a member’s journey including diagnoses, social determinants of health (SDoH) risks, hospitalizations, and readmissions, and capture critical data insights to support informed care decisions.
Nurse liaisons also identify the members’ clinical and SDoH needs and ensure the right services are in place for when they return home. “What makes our program unique are our analytics and our ability to communicate and collaborate in real-time,” Spear says.
“Nursing is a beautiful, rewarding profession in general, and being able to be there for a patient, uninterrupted and only there to help them is an honor,” Brandi explains.
Meet Michelle, RN, Post Acute Care On-site Nurse Liaison
For Michelle, another on-site nurse liaison at CareCentrix, the idea to become a nurse was sparked during childhood. “My mom was a healthcare professional who worked the night shift and sometimes when she would rest during the day, I would act as her ‘nurse,’” she recalls.
After 23 years of working in healthcare, 15 of which have been spent as a nurse, Michelle joined CareCentrix nearly four years ago. “I was drawn to this role because I was interested in the insurance aspect of healthcare, and I’m grateful to be in a position where I can help members heal and recover,” she says.
One of those members was Thomas*, an elderly man who Michelle followed for several weeks while he was in and out of the ICU and experiencing multiple setbacks.
Although Thomas’ physical and occupational therapists and case manager recommended that he should transition to a skilled nursing facility (SNF), he was very adamant that he wanted to recover in the comfort of his home. In conversations with him and his family, Michelle learned that he had home health care and durable medical equipment (DME) already in place, and plenty of support since his wife had recently retired from her job to be his primary caregiver.
“Based on the information I was able to gather and the trusted relationship I had established with him and his family, I knew that if he went to a SNF, it would not suit him, and he likely could have a better outcome at home,” Michelle recalls.
After creating a personalized next site of care recommendation based on Thomas’ medical condition and preferences for care, Michelle worked with the hospital case manager and made the case that transitioning him home with the support of his family was the optimal decision. The team agreed, adjusted their care goals to prepare him, and he ultimately was discharged home.
A few days post-discharge, Thomas’ wife texted Michelle a photo of him at home and told her how much of a blessing she was to advocate for him. She wrote, thank you for your help with Thomas. Your honesty and guidance were a blessing. You went above and beyond to help us and that is rare these days. I thank you from the bottom of my heart.
“When members can discharge to their homes, it makes a big difference in their healing and recovery process,” Michelle says. “The best part of my job is that I get to advocate, guide, and teach patients about the beginning journey of their recovery at home.”
Since many members are quite ill and conversations can be difficult or sometimes impossible for them, the nurse liaisons also work with their families and caregivers to help understand the member’s goals of care so they can advocate for their needs.
Supporting The Healing Journey Home
As the members prepare to discharge, nurse liaisons also provide information about the CareCentrix Readmissions Management team, including our nurse coaches, who reach out to members shortly after they return home. “We let them know that if things are still not making sense, or they feel overwhelmed, our readmissions management team will support them with whatever they need next,” Brandi says.
For CareCentrix nurses, their courage, dedication, and passion for their work are evident in everything they do. Their personal stories and intrinsic motivation are what led many of them to a career in nursing, where they come alongside patients with compassionate, patient-centered care every day.
Once members return home, they can continue receiving support through our Post Acute Care Readmissions Management solution team of registered nurses, registered dieticians, pharmacists, social work coordinators, patient advocates, and care coordinators who ensure optimal care coordination is in place to help them heal and prevent unnecessary hospital readmissions.
These post-acute care solutions ultimately lead to improved health outcomes, a reduction in unnecessary post-acute care facility utilization and costly hospital readmissions, and a boost in Star ratings. To learn more about how our post-acute care solutions can optimize your member outcomes and experiences while reducing costs, contact us today.
*To maintain members’ privacy, names and other potentially identifying details have been changed.
Sources:
- Based on CareCentrix Data Analysis 2022
EDRC 2302 052025
