Care Coordination Best Practices at Nourish

At Nourish, we hold Collaboration with the Clinical Community as a core value. Effective care coordination is essential to delivering high-quality, patient-centered care. As dietitians in an outpatient telehealth setting, our role extends beyond providing nutrition expertise—we are integral members of a multidisciplinary team. By collaborating with other healthcare professionals, we ensure patients receive comprehensive care that supports their overall health and well-being.

Below, we outline best practices for care coordination, including when and how to refer patients, effective communication strategies, and examples of collaborative approaches.

Knowing when to refer is critical to maintaining professional boundaries and ensuring patients receive appropriate care. Common referral scenarios include:

• Indicators: Depression, anxiety, difficulties with daily functioning, suicidal ideation, or relationship challenges.

• Referral: Connect the patient with a mental health profession such as a therapist, psychiatrist for psychotherapy or medication management. If they don’t have these providers established, you can also connect with their primary care physician (PCP) to discuss mental health support for a patient.

• Indicators: Need for diagnostic tests, medications, or medical interventions outside the dietitian’s scope.

• Referral: Direct the patient to their PCP or a specialist (e.g., endocrinologist, cardiologist etc.).

• Indicators: Need for structured exercise plans, injury rehabilitation, or mobility improvement.

• Referral: Recommend a physical therapist or a certified personal trainer as appropriate.

• Indicators: Difficulty with basic tasks like cooking, dressing, or maintaining mobility.

• Referral: Suggest an occupational therapist or physical therapist as appropriate.

• Indicators: Housing instability, food insecurity, or financial challenges.

• Referral: Refer to a social worker or local community resources for assistance.

• Policy: Patients with eating disorders should always have a multidisciplinary treatment team that includes a mental health provider and often a medical professional. First steps of Eating Disorder care should be support the patient in getting a team together.

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Take continuity of care into careful consideration when making referrals. If a patient has an established relationship with a provider, referring them to a new provider can disrupt continuity of care. This disruption may lead to fragmented communication, delays in treatment, duplication of services, and confusion for the patient, all of which can negatively impact patient outcomes. Whenever possible, prioritize maintaining existing provider relationships to support coordinated, seamless care. If a referral is recommended,  communicate the recommendation first with the referring provider. Provide all relevant information to both the referring provider and the patient to support continuity of care and a well-coordinated transition to the receiving provider.

Clear communication between providers creates a unified treatment approach. Reasons to reach out include:

• Aligning treatment plans: Ensuring that nutrition interventions complement medical or psychological care.

• Sharing updates: Informing providers of significant health changes affecting treatment.

• Seeking guidance: Consulting about aspects of a patient’s health or care plan that are unclear.

• Obtaining medical history: Gaining a comprehensive understanding of past or concurrent treatments.

Before a patient’s first appointment, carefully review any notes provided by the referring provider. These notes often contain critical details about the patient’s medical history, current treatment plans, and existing conditions.

Keep in mind that the patient’s primary concern may not always align with the referring provider’s focus. To ensure comprehensive care, it’s essential to address all relevant nutrition concerns, balancing both the patient’s priorities and the referring provider’s recommendations.

There are various methods to contact and communicate with providers, and it’s important to consider their preferences. Providers may have specific communication methods they prefer based on the systems they use or their scheduling constraints.

• Automatic Chart Notes: When a provider is added to a patient’s care team in the patient’s profile, chart notes are automatically faxed to them as soon as they are signed and locked.

• Medical Record Requests: If you want to request medical records from an external provider use the Medical Records Request Form found here.

• One-Off Requests: If you need to send specific documents (outside of routine chart notes), you can request a fax through support@usenourish.com. Read more in this FAQ.

• If you have a provider's email address, it can be an excellent tool for asynchronous communication. Email is ideal for introducing yourself, sharing brief updates, or arranging more in-depth discussions. Many therapists prefer this method of communication.

• Sample Email Template:

Subject: Care Coordination for [Patient Name]

Hi [Provider’s Name],

I’m [Your Name], a registered dietitian working with our mutual patient, [Patient Name]. I’m reaching out to touch base on care coordination. I’d love to find a time to chat further about this patient. Their Release of Information form is attached.

Here are some my available times I have available in the next week:

• [Insert Time 1]

• [Insert Time 2]

• etc.

Please let me know what works best for you or if there’s another time you prefer.

Kind regards,

[Your Name]

[Your Contact Information]

• Office Calls: Call the provider’s office directly. If the provider is unavailable, leave a detailed message with the nurse’s line or front desk staff.

• Nurse Assistance: Nurses often can act as intermediaries, conveying messages or providing patient updates.

If you find yourself disagreeing with another provider's treatment plan or recommendations for a shared patient, take a collaborative and respectful approach to resolve the concern:

1. Reach Out Directly: Initiate a professional conversation with the other provider to discuss your concerns. Avoid making assumptions—open dialogue is key to understanding their perspective.

2. Listen to Their Rationale: Take the time to hear the reasoning behind their treatment plan or recommendations. Understanding their clinical thought process can provide clarity and foster collaboration.

3. Share Your Perspective: Present your concerns in a clear and professional manner. Offer any supporting evidence-based research, clinical guidelines, or relevant patient-specific information (e.g., symptoms, history, or preferences) that may influence the care plan.

4. Work Toward Alignment: The goal is a unified, patient-centered care plan. Collaboratively discuss possible alternatives or adjustments that align with the best interests of the patient and ensure continuity of care.

It is important to document care coordination efforts with external providers in the Intervention Details section of a chart note. Accurate documentation ensures a clear record of collaboration, enhances continuity of care, and supports the patient's overall treatment plan.

To streamline this process, consider creating smart phrases for care coordination interventions you frequently perform. This can save time and ensure consistency in your documentation. Below are some examples of how to document care coordination effectively:

"Coordinated care with patient’s PCP. Discussed the patient’s current medication regimen and its potential relationship with reported GI issues. The PCP will address these concerns at the patient’s next follow-up appointment. Explained ongoing nutrition interventions to support GI health."

"Coordinated care with patient’s primary therapist. Shared updates on the patient’s progress and discussed how nutrition counseling aligns with the patient’s therapeutic goals."

A patient with Type 2 diabetes reports depression affecting adherence to their meal plan. You contact their PCP to confirm awareness of these concerns and recommend involving a therapist for mental health support.

A patient shows signs of iron deficiency despite following the prescribed nutrition reccomendations. You review lab results from their PCP, document the discussion and potential recommendations for supplementation, and coordinate care with their provider as needed.

You are working with a patient with Anorexia Nervosa who also has a therapist. You reach out to the therapist and discuss e-mailing patient updates every other week to ensure you are both receiving all relevant and important information about the patient’s progress and health status to ensure care plans align.

Collaboration is the foundation of holistic, patient-centered care. It bridges gaps in treatment, enhances health outcomes, and fosters trust between healthcare providers. At Nourish, proactive engagement with the broader clinical community reflects our commitment to exceptional patient care. By prioritizing care coordination, we ensure that every patient receives the comprehensive support they need to thrive.