Center for Improving Value in Health Care
Feb 27, 2017 | 0 comments | Posted by Global Administrator
Integrated Care, CMMI, Navigator, Change Agents
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.
1. SHG decided that they were going change how they worked together as a team and how they would serve people.
2. Worked with Otero Junior College to train Health Navigators to infiltrate the health care systems.
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.
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.
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.
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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