Nurse Care Coordination During the COVID-19 Pandemic

Providing patients with high-quality health care helps prevent diseases and improve their overall quality of life. Six in ten Americans live with at least one chronic high-risk disease, such as diabetes, cancer, heart disease, or stroke (Centers for Disease Control and Prevention [CDC], 2026). Although more resources are dedicated to healthcare per capita in the United States than any other nation, chronic high-risk diseases like these are a prominent cause of disability and death in the United States. These are a driving force for the ever-skyrocketing cost of health care. According to the CDC (2026), “90% of the nation’s $3.5 trillion in annual health care expenditures are for people with chronic and mental health conditions.” This is a growing concern, and we need to take direct action to resolve this issue.

Background

Nurse Care Coordinators have been synchronizing and organizing care for high-risk patients who suffer from chronic conditions since the turn of the last century (American Nurses Association [ANA], 2021). Nurse Care Coordination is a key component in improving quality patient care that is both effective and utilizes available resources efficiently. Karam et al. (2021, p. 16) state that care coordination is a “…core dimension of integrated care and a key responsibility for primary healthcare.” If medical care is not planned and executed, these high-risk patients are at an even greater risk for hospital readmissions and emergency department visits. This contributes to additional healthcare expenditures. These patients are also at a heightened probability of experiencing a medication or medical error due to their complex health needs. Khullar and Chokshi (2018, p. 1) affirm that “Better (nurse) care coordination…is a remedy for a fragmented health system and could lead to improved health outcomes, superior patient experiences, and lower costs.” Higher overall medical costs are also associated with high-risk patients. The Institute of Medicine (IOM) estimates that “a potential opportunity of $240 billion in savings would result from care coordination initiatives such as patient education and the development of new provider payment models” (National Quality Forum (NQF), 2022). Atherly & Thorpe (2011, p. S23), as cited in Camicia et al. (2013), state that Nurse Care Coordination “Showed significant cost reductions among high-cost, chronically ill Medicare patients by using an interprofessional clinical team and nurse care coordination to educate and empower patients.” Nurse Care Coordinators are vital in controlling patient costs while attaining value in the ever-changing healthcare system.

Nurse Care Coordinator Role

Nurse Care Coordinators assist in integrating patient-centered care to improve the quality, evidence-based care, and overall effectiveness of services. “Care coordination occurs when there is deliberate coordination of a patient’s care and sharing of information across multiple providers and settings” (Benjenk, et al., 2020). A study by Camicia, et al., (2013) found that Nurse Care Coordinators contributed to:

• Reductions in emergency department visits
• Noticeable decreases in medication costs
• Reduced inpatient charges
• Reduced overall charges
• Average savings per patient
• Significant increases in survival with fewer readmissions
• Lower total annual Medicare costs for those beneficiaries participating in pilot projects compared to control groups
• Increased patient confidence in self-managing care
• Improved quality of care
• Increased safety of older adults during transition from an acute care setting to the home
• Improved clinical outcomes and reduced costs
• Improved patient satisfaction overall

Overall, nurse care coordinators positively impact all patients to whom they provide care. Nurses and Nurse Care Coordinators are valued, trusted healthcare professionals. According to Gallup® (Saad, 2022, p. 3), “For the 20^th straight year, nurses lead Gallup’s annual ranking of professionals for having high honesty and ethics, eclipsing medical doctors in second place by 14 points.” Nurse Care Coordinators form a meaningful, professional working relationship with their patients to build trust and advocate for the patient’s needs. By establishing these working relationships, Nurse Care Coordinators can continue to develop a strong connection with their patients.

Nurse Care Coordinators work closely with their coworkers and the primary care provider to identify patients who will benefit from interventions and enrollment in longitudinal care management. It is essential to understand the needs and goals and develop a personal care plan for optimal outcomes and quality care for the patient. Nurse Care Coordinators play a vital role in improving the overall delivery of healthcare while enhancing patient experience, reducing costs, and improving outcomes for diverse patient populations. Overall, the dedicated involvement of the Nurse Care Coordinator in the patient’s overall care can significantly improve the patient’s health and reduce overall healthcare costs.

Care Coordination Defined

The definition of Care Coordination can vary, but they are all very similar. The Agency for Healthcare Research and Quality (McDonald et al., 2007) defines care coordination as, the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities. It is often managed by exchanging information among participants responsible for different aspects of care.

Care coordination can also be described as a structured approach to ensure that the patient's needs and preferences are met through effective health service delivery and unified information sharing across care settings and individuals. It involves the organized planning of patient care activities among various participants, including the patient, to promote the efficient delivery of healthcare services. Nurse Care Coordinators play a vital role in reducing barriers to care, improving patient access to quality services, and lowering costs within the healthcare system.

Patient Benefit of Nurse Care Coordination

Many patients benefit from Nurse Care Coordination due to the complexity of their various health problems, their social situation, and the required health services. According to Karam et al. (2021, p. 2), “Fragmentation of health and social care services causes patients with complex needs to bear the major responsibility for navigating their pathway through services and providers, and they experience systems as being confusing and overwhelming.” The goal of a Nurse Care Coordinator is to fulfill the needs of the patients they serve by delivering high-quality health care to meet their patients' goals.

Nurse Care Coordinators handle this role by helping patients with transitions of care, such as discharge from a hospital to home, developing a care plan with the patient that aligns with their goals, assessing the patient’s social determinants of health, connecting them to necessary community resources, and following up to ensure proper care. Patients supervised by Nurse Care Coordinators often gain greater confidence in managing their care and better understanding of preventative measures they can take to improve their health. Registered nurses recognize their vital role in care coordination, working carefully to improve patient outcomes, foster effective interdisciplinary collaboration, and reduce costs across various patient groups and healthcare environments. Effective nurse care coordination is essential to meet patients' needs. It can improve patient outcomes, especially in high-risk populations requiring complex treatments and prone to recurrent hospital stays. Without this, there's a risk of unmet needs and fragmented care. Through support and targeted education, Nurse Care Coordinators can assist in managing symptoms, helping to prevent costly hospital admissions and readmissions.

The Nurse Care Coordinator is central to the overall health and well-being of patients with chronic health conditions. These patients are particularly vulnerable and require extra nursing support for superior care outcomes. The patient's care needs can get lost, disorganized, or not shared if the patient is receiving care from their primary care provider and specialist providers as well. They can also have providers from many healthcare organizations. Since all healthcare organizations do not use the same electronic health record (EHR), sharing patient information and care plans with these providers is challenging. When care is disorganized, it can lead to unnecessary visits to the emergency department, medication errors, and readmissions to the hospital, which could have been possibly prevented by care coordination.

Foci of Nurse Care Coordinators

Nurse Care Coordinators focus on many aspects of care for the patients they serve. They focus on teamwork in providing collaborative care to patients with other healthcare team members, including the primary care physician, medical assistants, pharmacists, behavioral health consultants, social workers, and community workers. Nurse Care Coordinators also assist with establishing home care service needs for patients. Knowledge is shared regarding medication management, resources to support the patient at home, and providing optimal care and services to prevent potential hospital readmissions within 30 days.

Advocacy is also of vital importance in the world of healthcare. The Merriam-Webster dictionary defines advocacy as “the act or process of supporting a cause or proposal” (2026, p. 1). While some patients can advocate for their health needs, many are not due to various reasons. Nurse Care Coordinators advocate for their patients while including their family members and caregivers to provide holistic care. The Nurse Care Coordinator works with patients to achieve their goals, values, preferences, and needs. Through advocacy, Nurse Care Coordinators positively impact patients’ lives.

A Nurse Care Coordinator can help organize the patient’s care and assist with care across the continuum. Heslop et al. (2019, p. 2) reinforce that Nurse Care Coordinators “…assist vulnerable populations navigate healthcare systems, maximize their levels of functioning, and quality of life and health status.…” This additional communication and organization of care can make disease management successful, thus preventing hospital readmissions and frequent emergency room visits. Khullar and Chokshi (2018, p. 1) confirm that “…[nurse] care coordination can lower rates of emergency department visits and hospital readmissions, particularly for older high-risk patients.…” This evidence underlines the significant role of nurse-led care coordination in improving patient outcomes and optimizing healthcare resources. By unnecessary hospital utilization, particularly among vulnerable populations, effective care coordination contributes to improved quality of care, increased patient satisfaction, and cost savings within the healthcare system.

The American Nurses Association and the Healthcare Aims

According to the ANA (2021), care coordination is essential to achieve the Triple Aim of health reform care (improved patient care experience, improved population health, and per capita cost control). This position statement articulates the essential role of the Registered Nurse in the care coordination process. Overall, the Registered Nurse focuses on improving patients' care and complete health.

The ANA’s Position Statement (2021, p.1) declares,

(1) Patient-centered care coordination is a core professional standard and competency for all registered nursing practice. Based on a partnership guided by the healthcare consumer’s and family’s needs and preferences, the Registered Nurse is integral to patient care quality, satisfaction, and the effective and efficient use of healthcare resources. Registered nurses are qualified and educated for the role of care coordination, especially with high-risk and vulnerable populations.

(2) In partnership with other healthcare professionals, registered nurses have demonstrated leadership and innovation in designing, implementing, and evaluating successful team-based care coordination processes and models. Registered nurses' contributions to care coordination services must be defined, measured, and reported to ensure appropriate financial and systemic incentives for the professional care coordination role.

Nurse Care Coordinators influence patient care at every level and are fundamental to quality patient care and patient satisfaction. Swan et al. (2019, p. 317) found that effective Nurse Care Coordination helps support the Quadruple Aim (adapted from the Triple Aim). The Quadruple Aim focuses on improving patient care, improving the health of individuals, enhancing the work life of healthcare providers, and decreasing costs. These actions can improve the health of patients. Nurse Care Coordinators have regularly played a pivotal role in the longitudinal care of patients with chronic health diseases. The ANA identifies and strongly endorses the essential role Registered Nurses play in the care coordination process to advance healthcare quality and outcomes of patients across vast patient populations and healthcare settings.

Nurse Care Coordinators focus on connecting patients with essential resources, providing education and support, and helping synchronize many healthcare services for patients with complex needs. It is an overall multifaceted approach to providing care to patients. These specialized nurses help to improve a patient’s overall care and assist with interprofessional collaboration across a broad spectrum. As Hannigan et al. (2018, p. 10) declare, “…(nurse) care coordination is work which absolutely has to be done. When done well, it connects the person with the system of care surrounding them and is accomplished in interpersonally skilled, collaborative ways which promote recovery.” This targeted care coordination can potentially improve the safety and health of high-risk patients.

Nurse Care Coordination During the Pandemic

Nursing continues to adapt and respond to the ever-demanding changes in our healthcare system today. Providing interprofessional collaboration and communication allows Nurse Care Coordinators to achieve patient-centered goals. Nurse Care Coordinators continue to advocate for healthcare consumers, adults, children, the underserved, and the public. Overall, Nurse Care Coordinators optimize patients' health and safety.

Nurse Care Coordinators have also significantly contributed to the fight against Coronavirus disease (COVID-19). COVID-19 is an infectious disease caused by the SARS-CoV-2 virus (World Health Organization [WHO], 2026). COVID-19 has had a devastating impact on numerous individuals. It has especially affected high-risk individuals with chronic diseases, especially those with pulmonary conditions such as chronic obstructive pulmonary disease (COPD). Some patients who have yet to fully recover from COVID-19 weeks or even months after first experiencing symptoms (known as long haulers) can be considered high-risk patients as well. According to the Centers for Disease Control and Prevention website (CDC, 2026), the number of deaths in the United States attributed to COVID-19 on death certificates as of February 22, 2025 was 1,224,551. The WHO (2025) reported that as of February 12, 2025, there have been 7,089,979 world-wide COVID-19 deaths. Sadly, the number of patient deaths continues to climb every day due to COVID-19.

Most individuals with COVID-19 experience mild to moderate respiratory and cold-like symptoms and recuperate well at home. Patients eligible to receive COVID-19 and booster vaccinations are encouraged to do so by the healthcare provider, especially if they have a compromised immune system or chronic health conditions. Nurse Care Coordinators have been key in informing patients about the available vaccinations, the benefits of wearing a mask, washing their hands, ensuring good ventilation indoors, physically distancing, and avoiding crowds. Nurse Care Coordinators were also knowledgeable in answering patients’ questions regarding their COVID-19 symptoms, how to interpret results on their pulse-oximeter, home isolation guidelines, when to seek emergency room care or call 911, and questions regarding COVID-19 overall. Providing this information to patients helped them understand the facts, actions they could take to prevent COVID-19, steps to prevent the spread of COVID-19 to others, and steps they should take to help them recover if they were infected.

Sample Activities of Nurse Care Coordinators During COVID-19

High-risk patients who were COVID-19 positive and needed to be in home isolation were at risk for anxiety or depression. For example, at a leading hospital in the Philadelphia region, Nurse Care Coordinators connected with these patients telephonically who needed additional support. Through these conversations with patients, the Nurse Care Coordinator was able to relay new information about the patient to the primary care provider and help them set up follow-up appointments with their provider as well. These actions successfully prevented hospital readmissions for high-risk patients and provided them with additional guidance.

Older adults and individuals with chronic diseases are often at a higher risk of developing complications and require hospitalization from COVID-19. Patients with chronic diseases who were at home and tested positive for COVID-19 and/or those discharged from the hospital or emergency room tested positive for COVID-19 were closely followed by nurse care coordinators to ensure their recovery and help treat symptoms as they arose. The Nurse Care Coordinator continued to collaborate with the primary care provider and the team to provide optimal care to the patient, relay questions, and provide much-needed support to the patient.

Effective discharge planning is essential to ensuring the patient has everything they need to recover at home and successfully prevent readmissions. During a discharge call to these patients, the Nurse Care Coordinator would review the discharge instructions with the patient and complete a medication reconciliation as well. The Nurse Care Coordinator would use the teach-back method with the patient to ensure they understand the information correctly. They scheduled an office visit with the primary care physician for the patient within seven days after their hospital discharge. If a patient were discharged from the hospital with a positive COVID-19 test, there would be a specific focus on symptom management and red-flag symptoms of COVID-19.

Nurse Care Coordinators continued educating high-risk patients about their chronic health condition(s). The Nurse Care Coordinator followed many patients with chronic conditions for 30 to 90 days for longitudinal care management, which included further education and check-in phone calls. When patients were considered stable and met their goals, they graduated from the intervention. Overall, Nurse Care Coordinators were essential in ensuring patients had the support and services they needed during the COVID-19 pandemic.

Conclusion

Nurse Care Coordinators are essential to patients' well-being, recovery, and overall health. Nurse Care Coordinators showed strength, resilience, and courage during the COVID-19 pandemic. We have truly lived the definition of nursing as defined by the ANA (2022, p. 2), “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.” As the COVID-19 pandemic waxes and wanes, Nurse Care Coordinators continue to provide quality care to patients, advocate for the needs of patients, provide education and support, and endeavor to protect the health of each patient they care for.

Overall, Nurse Care Coordinators continue to provide quality care to high-risk patients affected by COVID-19. Nurse Care Coordinators are vital in providing care to high-risk patients with chronic diseases in the primary care setting. The care provided is more cohesive and meets the multifaceted needs of the patients it serves.

Author

Christina Gresh, MSN, BSN, RN
Email: c.gresh2009@yahoo.com

Christina Gresh, MSN, BSN, RN, is a Registered Nurse Inpatient Case Manager. She earned her degrees at Gwynedd Mercy University and Immaculata University. She is a dual chapter member of Sigma Theta Tau International Honor Society of Nursing. Her professional interests include advancing excellence in patient care and contributing to peer review and editorial work in nursing.