Buscar

When thinking about taking care of your total health, what comes to mind? Perhaps participating in your annual check-ups, taking your prescribed medication, eating a nutritious diet, checking in with your mental health, the list goes on and on.   Now, put yourselves in the shoes of someone who may not know where their next meal may come from, someone who may be homebound and not have access to transportation, someone who may be on a fixed income, someone facing homelessness or even someone who may be struggling with substance abuse issues. Getting healthy – and staying healthy – comes with a unique set of obstacles, or social determinants of health, for these patients to overcome. Inequities around social determinants and health behaviors have an outsized impact on patient outcomes, and social and economic factors make up 40 percent of those inequities.  This is where the caring and compassionate community health workers, social workers and registered nurses that make up Renown’s Community Care Management (CCM) department rise to the occasion. As the need for resources grows in northern Nevada, these dedicated team members fill those gaps and ensure every patient feels prepared, educated and equipped with everything they need to continue their care journey and live a healthy, fulfilling life.  Defying Disparities  When our community at risk faces healthcare disparities, it can create complications in each patient’s life that may keep them from addressing their healthcare needs and affect the likelihood of them being admitted or readmitted to the hospital or continuing to struggle with their care management – but not on CCM’s watch. Whenever possible, the CCM team steps in to provide critical resources, education and care journey guidance for any patient that finds themselves in need.  “In the simplest terms, we do outpatient case management with vulnerable populations,” said Barb Mader-Scherrer, Director of Community Care Management. “It may be anyone from elderly people who need help managing chronic diseases, to patients experiencing homelessness who are being discharged from the hospital. We work with folks who are facing all sorts of challenges.”  Several roles make up the CCM department, including Community Health Workers. These team members are the resource experts, on the front lines of helping educate patients and supporting them as they navigate through the facets of their care. Their main goals? Avoid admissions and readmissions to the hospital and continue to meet their unique goals.  “I have the pleasure of working with patients who may need financial help, transportation help or even help utilizing the food pantries in our community," added Steve Arm, Community Health Worker. “We help patients navigate healthcare and social services, address social determinants of health, encourage self-efficiency and provide general health education for many chronic conditions. We also provide home visits for our patients who need extra support.”  “The day in the life of a Transitional Community Health Worker is to outreach to the patient while being admitted, do a bedside assessment, complete the social determinants of health evaluation and provide any resources needed to avoid readmission,” added Sherrie Skaggs, Community Health Worker. “Our main population is Medicaid, and many are homeless and financially challenged. As needed, we continue to ensure that follow-up is completed, and all needs and goals are met.”  For those learning to cope with their condition and needing hands-on help especially after discharge, the CCM Social Work Care Coordinators take on this complex aspect of the healthcare journey. These individuals provide support and intervention for Renown patients facing a chronic, behavioral health or substance dependency condition to improve their overall quality of life beyond hospital walls, developing a strong framework to build a long-term healthcare plan.   “As social work care coordinators, we help connect patients with mental health resources, welfare programs, community support, caregiver burnout resources, placement for loved ones with terminal illnesses and much more,” said Irina Osmolovska, Social Work Care Coordinator. “Requests that come to us run the gamut of homelessness, family crisis, food insecurity and even situations where a patient has no electricity for their life-saving medical equipment. We receive challenging requests and are always ready to go above and beyond to advocate for our patients.”  Possessing a profound understanding of the delicate balance between medicine and the patient spirit, the CCM RNs help bridge the gaps between the hospital or primary care practice and post-discharge settings, ensuring a smooth transition for patients as they move from one healthcare setting to another. With their expertise in care coordination and patient education, these RNs help enhance patient outcomes and promote continuity of care.  “Our group is responsible for making discharge follow-up calls to patients who have Medicare, as well as scheduling their hospital follow-up visit if needed,” said Vanessa Alford, Consulting RN. “The goal is to have every patient see their primary care physician within 14 days of discharge for continuity of care and to prevent readmissions. We also screen patients for eligibility for Chronic Care Management or Personal Care Management. In addition to setting up the patient for follow up, I review each patient's medications, answer any questions they may have about their medications and health conditions.”  As another important part of unpacking the intricate web of social determinants impacting health, CCM RN Care Coordinators have the extraordinary opportunity to extend this department’s compassionate care beyond the boundaries of the traditional in-office environment. Whether it be through virtual connections, heartfelt conversations over the phone or in-person encounters outside the hospital, RN Care Coordinators create holistic and enduring plans of care for individuals facing chronic challenges – including behavioral health issues and chemical dependency struggles – at every stage of life.  All in all, the CCM department recognizes the interconnectedness of physical, emotional and social well-being for all patients, fostering a sense of wholeness and empowerment to ensure they continue to meet their goals and live healthier, happier lifestyles.  “Our team has a holistic approach to our work,” said Barb Mader-Scherrer. “We look at the whole picture. What are the medical things we can do for this person? What education do they need to help them manage their condition? Do they have food in their house? Do they have a safe living environment? Are there substance abuse issues? Do they need help in managing their medications?”  “My 18 years of experience in various areas of hospital nursing and home health have given me the knowledge to serve patients in our community holistically, and I feel good about what I do,” added Vanessa Alford. “I hope that I am able to lessen the load on the medical assistants and providers in the clinics so they can focus on their patients on site.”

Read More About Department Spotlight Community Care Management