“I did not have a clue how to proceed.”

Care coordinator Burlay Parks meets with a patient at Greeley County Health Services in Tribune, Kansas. Photo by Chrysanne Grund.

Care coordinator Burlay Parks meets with a patient at Greeley County Health Services in Tribune, Kansas. Photo by Chrysanne Grund.

The opening sentence of “Pathfinding on the Frontier,” the In the Community column in the October issue of AJN, alludes to the confusion even the most organized and savvy person sometimes feels when navigating our health care system.

In rural settings, referrals to specialists from primary care providers can be difficult for patients and families to follow up on, sometimes requiring that patients travel great distances.

Patient care coordination has been shown to decrease the number of ED visits and hospitalizations. The authors of this article explore care coordination in two Kansas counties, presenting three case studies showing how a nurse care coordinator—as part of a program at a rural primary care practice funded by a two-year grant from the Robert Wood Johnson Foundation—resolved complex issues for seriously or chronically ill patients involving medications, specialists, and diagnoses.

Reading the details of each case, nurses may recognize the ways patients can get lost and forgotten in the system, and the ways a care coordinator’s persistence and experience may pay off in helping them get the care they need.

To read the entire article, click here.—Jacob Molyneux, senior editor

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