Juan Romero is a 4th generation Southwest Coloradoan who proudly traces his family history back to the 1500s. Last year, an alarmed disability health screener told Romero to immediately go to the hospital because of concerns over his high blood pressure and cholesterol. When he arrived at the front desk, he was told to go to the Emergency Room. After adamantly refusing to incur unnecessary debt, Romero was referred to Helen Joline, a Nurse Navigator with San Juan Basin Health's Care Coordination Team of the Southwest (CCTSW). Looking back, he reflects, "I didn't know what kind of help I needed or which way to turn.” Romero’s now the healthiest he’s been in a decade, and he credits his Nurse Navigator.
Joline is one of three Nurse Navigators on the team that ensures a continuum of care. While each focuses on a particular age range, they can extend services to other family members when appropriate, thereby addressing the family unit as a whole. So not only was 58 year old Romero assisted by Joline, the designated "adult nurse navigator", but so too was his 92 year old mother.
Just entering its second year, this locally funded pilot model was tasked with the dual goals of producing better health outcomes and decreasing cost. CCTSW accomplishes these by (1) decreasing ER visits; (2) decreasing inpatient readmits; and (3) decreasing duplicative costly imaging services being ordered from multiple providers. “By sharing our data with partners,” explains Vanessa Boyd, Care Coordination Team manager, “we can target duplicative services and allow clients to move around between providers more effortlessly, safely and effectively."
During 2012, the three Nurse Navigators (2 FTE) worked with over 400 referrals and an average caseload of about 70 clients per month. Clients are primarily individuals that have been identified as having two or more chronic diseases, one of which can be behavioral health, and a non-medical barrier to care such as transportation, daycare, lack of pay source, lack of insurance, or language. Along with high blood pressure, for instance, Joline discovered Romero had diabetes and no transportation. Barriers to care are identified by the Nurse Navigators and reported as trends for systems to work to eliminate those barriers.
San Juan Basin Health had several existing programs that are now under the umbrella of the CCTSW program due to their complimentary goals and vision. These include the Healthcare Program for Children with Special Needs Healthy Communities (Medicaid/CHP+ enrollments and case management), a Temporary Assistance to Needy Families (TANF) program public health nurse, and a Promotora (bilingual, bicultural health educator). In addition, Single Entry Point program and behavioral health case managers come together on a regular basis which Boyd said is “wonderful for case conferencing but also critical to building systems that will address barriers to care.”
These programs all serve a medical home framework by providing a referral network, support for chronic disease management plans and early detection through screenings, and establishing payment sources.
Referrals come from a wide variety of agencies across the community including: social workers, physicians, youth services, case managers at local hospitals, nursing homes, and Rocky Mountain Health Plans' (RMHP) Regional Collaborative Care Organization (RCCO) which contracts with San Juan Basin Health for care coordination services. Transitions of Care are a priority the Care Coordination Team works on through RCCO. When a patient is discharged from the hospital, "Our job is ensuring there's continuity of care which helps decrease return ER and inpatient visits," says Boyd. "It can lead to longer involvement with the individual depending on their level of health and need."
CCTSW is a private/public partnership that provides a base from which to outreach to other agencies and private entities. Contributing partners include RMHP, Mercy Regional Medical Center, Pediatric Partners of the Southwest, Axis Health System, and La Plata County. Representatives from these agencies and offices, along with other supporting partners, meet monthly as an oversight committee through the Southwestern Colorado Area Health Education Center.
“It’s been amazing to witness the power of innovative partnering in our community to improve health care access,” said Joe Theine, San Juan Basin Health Director. As a partner helping to guide this pilot project, Theine says “I’m very pleased with our accomplishments in just the first year. These include directly assisting clients obtain needed care, developing a system to connect clients with providers and agencies, expanding the number of partnering organizations and learning from our experiences to improve access to care in our community.” Theine believes that they are building a sustainable program with many elements that can be replicated in other communities.
Communities attempting to address better health care face a lot of competing priorities. This collaborative has made a solid start in the Southwest Colorado community while at the same time assisting individuals in sorting out their competing needs and gaining control of their own health. CCTSW takes pride in keeping people like Romero from falling between the health system cracks by giving them the tools they need to stay healthy.
As the program evolves, protocols are being implemented including creating a client graduation (exit) from the program. "Our goal is getting them to a level of care that indicates the person is self-managing," said Boyd. Through a client-centered approach, clients formulate and follow a care management plan, establish a medical home that addresses their needs, and they know how and when to access care.
Both Joline and Romero agree that he has more than merely 'graduated'. He's content, healthy and able to take care of his 92 year old mom. "I'm at a place where I can cope with life's surroundings.” He credits Joline with taking charge when he was lost. "She guided me - she really is a navigator"
San Juan Basin Health serves residents in La Plata and Archuleta counties in Southwestern Colorado. Jane Looney is the Communications Director for San Juan Basin Health. You can reach her at 970-335-2087 or firstname.lastname@example.org.
Photo courtesy of San Juan Basin Health. Pictured right, Helen Joline, pictured left, Juan Romero.