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New Care Coordination Program Begins in McCall

Registered nurse care coordinators Angela Richardson and Shannon Nelson work on developing the processes for the new care coordination program in McCall.
June 18, 2014

McCALL, Idaho - A newly insured patient, concerned about an outstanding medical bill incurred before obtaining coverage, is one of the first to benefit from a new path into health care. St. Luke’s McCall was able to refer the patient to Patient Navigator Lindy Carr, who identified a program that provided financial assistance.

It’s these details that make all the difference, and St. Luke’s McCall and its medical clinics are helping patients attend to all the details in new and very patient-centered ways.

“We are in the beginning stages of a new program that helps patients identify their healthcare goals and gives them tools to help accomplish their goals. Already this has led to a much improved visit for a patient with their doctor,” said Shannon Nelson, RN, patient coordinator.

The new care coordination model is designed to improve access to care, improve outcomes, and create efficiencies. It will help patients who have typically sought their medical care through the free Community Care Clinic or emergency department, easing their transition into traditional health care and identifying a primary care doctor to manage their care. The goal is for patients to be engaged and in control of managing and improving their health by accessing the appropriate care and utilizing resources that are available to all patients.

Candidates for the care coordination program are patients with complex medical needs who recently have become insured through Your Health Idaho, the new health insurance exchange. For some patients, this is the first time they have had health insurance. Patients are being referred to participate in the program by Carr and healthcare providers at the free Community Care Clinic.

Registered nurse Shannon Nelson was hired to develop the framework and daily operations of the program. Nelson was able to learn about the successful care model implemented at St. Luke’s Clinic – Eastern Oregon Medical Associates’ family medicine clinic in Baker City, Ore., by Dr. Jon Schott and Mary Sterns, RN.

“Setting the groundwork for care coordination combines all the reasons I love being a nurse,” Nelson said. “Building a program from the bottom up and being able to have meaningful patient interactions feels like building a Lego model. There are so many combinations, sizes, shapes, and colors of bricks, but each is so important to making a lasting, sustainable structure.”

Taking over for Nelson, as the full-time care coordinator, is Angela Richardson, RN, who shares Nelson’s passion for the program. Dr. Jon Currey, St. Luke’s Clinic – Payette Lakes Family Medicine, will serve as the physician lead and will work with the nurse care coordinators on improving processes and on individual cases as needed.

“I am confident this model of care coordination will become a vital part of how we deliver care going forward. It will aid in improving our community members’ health and supports lowering costs,” Richardson said.

The coordinated care model is meant to:

  • Ease the transition of newly insured patients in accessing preventative and primary care.
  • Reduce emergency room visits, hospital admissions, and readmissions to the hospital.
  • Encourage appropriate use of resources through care coordination.
  • Make referrals to financial care navigation, behavioral health, dental, and social services.
  • Ensure the safety of each patient’s home environment.
  • Leverage technology and provide training and access to electronic resources, including education, St. Luke’s myChart electronic health records system, and more.
  • Provide opportunities for group education for chronic disease management and support.
  • Identify community partners and resources for health, safety, and transportation.
This program has been made possible through the physician leadership of Dr. Jennifer Gray, by encouraging and developing care coordination in McCall. A grant was received by the St. Luke’s McCall Foundation from the Cambia Health Foundation for $46,500 to fund program development.

The Cambia Health Foundation, based in Portland, helps support organizations that are working toward new solutions in providing patient-centered care that improves health and leads to less cost for the patients.