3-minute case study: Care coordination at the ready

  | October 30, 2018

Across the athenahealth network and beyond, healthcare organizations are designing and implementing simple interventions with outsized impact on outcomes, satisfaction, and success. Here's another.

The problem

At Samuel U. Rodgers Health Center, a federally qualified health center that treats more than 25,000 patients in Kansas City, Missouri, patients often arrive with urgent needs, such as acute depression or uncontrolled diabetes, and need more assistance and education than a physician can provide during a visit.

With minimal portal-adoption rates and low response to automated reminders, patients who leave without getting that support aren't likely to return.

The solution

To back up physicians and respond immediately to such cases, Samuel Rodgers created a three-person support team comprising a psychologist or social worker, a care coordinator, and a diabetes nurse educator – important because diabetes is the No. 1 chronic condition in the practice.

Physicians can refer to the team any patient needing diabetes education, mental health services, social services, or anything related to the upstream drivers of health.

If patients are referred for depression, the psychologist can often speak with them right then and there and get them connected to ongoing mental health services.

Likewise, the nurse educator is typically available immediately to counsel patients with uncontrolled diabetes on medication, diet and lifestyle, often sending them to Samuel Rodgers's in-house food pantry. If the physician wants to start insulin therapy, the diabetes nurse will usually give patients the first dose that same day.

For times when the social worker or diabetes nurse are not available, the care coordinator will schedule patients to be seen within 24 hours, sitting down to talk with them and making sure they are connected to the care team in some way before they walk out the door.

“If someone needs some kind of social item or medication but they can't afford it, I just put the note on the desk of the coordinator, and she takes it from there," says Anthony Gutierrez, M.D., an internist at Samuel Rodgers who has served Kansas City area patients for 32 years. “It's the best system I've ever had."

The outcome

Physicians at Samuel Rodgers are seeing better diabetes and hypertension control among their patients, and they credit the team model for those results. And physicians are able to see 20 – 25 patients a day, knowing each of them is getting the time and attention they need. The national average is about 20 patients per day, and that is often for a far less complex patient panel than is seen at Samuel Rodgers.

“Our outcomes are just better because of the team – we can really get people controlled because they are motivated and engaged," Gutierrez says. “These things are making a difference."

Lia Novotny is a contributing writer to athenaInsight.

3-minute case study: Care coordination at the ready