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Change Agent Chat Briefing, Southeast Health Group

The Change Agent Chat Series is a collection of interviews with boots-on-the-ground organizations and individuals working to advance lower cost and better care for all Coloradans. Join us on the 4th Friday of every month from 12-12:30pm MT.

On February 24th, CIVHC's CMO, Jay Want, sat down with Southeast Health Group's Integrated Care Director, Jackie Brown, to discuss their TIPPING Point program that integrates mental and physical health through health navigators.

  • Listen to the Change Agent Chat with CIVHC CMO, Jay Want, MD, and SHG’s Integrated Care Director, Jackie Brown, RN, MSN, APN
  • Read Southeast Health Group’s Change Agent Profile

The Situation

  • Many of Southeast Health Group’s (SHG) patients are low income. Some may have mental health challenges, chronic conditions, and may be homeless.
  • 60% of Medicaid funds are used by about 100 people in Prowers County

The Intervention

1. SHG decided that they were going change how they worked together as a team and how they would serve people.

  • Weekly meetings with entire SHG team
  • Created Health Navigator Program
  • Funded by three year grant from Centers for Medicare & Medicaid

2. Worked with Otero Junior College to train Health Navigators to infiltrate the health care systems.

  • First class had 24 people who were trained to look at people holistically and integrate care for patients.
  • Classes included Community Health Issues, Impact of Chronic Disease, Patient Navigation, and End of Life Palliative Care. (Click here for more info).
  • The program also required field experience with partner organizations.
  • Had to train not only the Navigators but also the patients and the providers how to use the Navigator.
    • Providers initially reluctant to accept the new program but saw the value after time. Five years later, the program is ingrained in the community and the providers look to SHG to help.
      • Providers now come to clinical meetings and share feedback about how the Navigator is helping.
      • Providers are confident that patients have someone helping them accomplish their health care goals.

3. Navigators are able to do whatever necessary to help the patients with the idea to teach people to self-navigate the health care system.

  • Transportation is one of the biggest needs in Southeast Colorado. Navigators drive patients to care as necessary.

4. Providers bring patients to SHG and the Navigator teams work to create warm transitions between types of care.

5. Once funding ended in 2015, the management and project teams came together to figure out a plan forward.

  • Went from six Navigators to four and added a Peer position that took over the transportation segment.
    • Patients love the Peers!
    • Health Navigators handle more complex cases.
  • Used some of the Regional Care Collaborative funding and received a grant from the Colorado Department of Public Health and the Environment.

The Impact

Patient Impact Case 1

A female patient, who SHG had been helping for about a year, reported that the local transit system’s bus driver told her she didn’t have the right type of Medicaid to get free bus rides. The Health Navigator looked at the patient’s Medicaid status and after several calls back and forth to the transit office; the team realized the patient did, in fact, qualify for free bus rides.

The Navigator also audited the patient’s medication supply, helping her read the labels and get rid of old medications. As a result, she seems to be functioning better, and has become more independent in her decision-making.

One of the hospital providers complimented the efforts of the Navigator and Hospital Liaison, stating that the patient had a history of showing up at the ER several times per week for socialization. It appears that since the patient has become involved with the Navigator and Hospital Liaison, her socialization needs are being met and the unnecessary ER visits have stopped.

Patient Impact Case 2

A female patient with a severe and persistent mental illness had a long history of poor hearing.  Her medical providers overlooked the problem, telling her it was all related to her mental illness and possible auditory hallucinations. The Navigator listened to her description of how and what she was hearing and decided to help her get a hearing test.

The patient did, in fact, have hearing problems, but the hearing aids to fix the problem cost $3,275. The Navigator helped her apply for funding, and she was approved for $2,200 through Friends of Man and $800 from the AV Hunter Trust.  The remainder has been requested from the in-house advocacy fund. The SHG team is excited to see how she feels once she has the hearing aids.

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Join us in March when we chat with HopeWest's President and CEO, Christy Whitney. Click here for more information and to register.

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