The following article is come The Essette Gazette 2015 ThanksGIVING Edition 2015.

Managing complex and chronic healthcare conditions can be extremely complicated for patients and their caregivers. Community Health Innovations (CHI), located in Monterey, California, is addressing those challenges with a comprehensive care management program designed to help patients, families and healthcare providers navigate care, manage complex health issues and locate community resources.

CHI has a team of dedicated nurse care managers who work within its healthcare community—in Patient-Centered Medical Homes (PCMHs), Community Hospital of the Monterey Peninsula’s emergency department and inpatient floors Anthem’s Enhanced Personal Health Care and with Aspire Health Plan’s Medicare Advantage patients.

Today, and as a retrospective celebration of National Case Management Week, Essette is honoring two of the dedicated nurse care managers who work at Peninsula Primary Care, a Patient-Centered Medical Home.

PCMHs are led by a physician and include a number of other allied professionals who help answer questions and coordinate resources in the care continuum. The PCMH model also strives to include better-quality and team-based care, improved patient experience, patient engagement, a focus on prevention and disease management and the reduction of unnecessary hospital visits. Its focus is on long-term partnerships between the patient and the entire care team.

The care model at Peninsula Primary Care places the patient in the middle of the clinical care team; one that’s best prepared to address his or her individual medical needs.

CHI has been recognized by the National Committee for Quality Assurance (NCQA) as a Level 3 PCMH— the highest distinction attainable to a medical practice. Its clinical care teams monitor health progress, track clinical results and health metrics, develop personalized care plans and coordinate community resources, ensuring that patients receive the highest quality of care—at the right time.

In the spirit of National Case Manager Week and, with the belief that it’s NEVER too late to say ‘thank you’ or to recognize people for their contributions to the healthcare community, Essette would like to introduce two special care managers who help make Peninsula Primary Care’s PCMH model so successful.

Why two? Because Kathy and Holly each represent unique roles within CHI’s collaborative clinical care team. A team responsible for:

  • Facilitating effective transitions as patients go between health settings and home
  • Providing clinical best practices and patient-centric care plans to help patients reach wellness goals
  • Educating patients, families and caregivers about proper health-condition and medication management
  • Assisting patients and providers in reducing unnecessary costs
  • Supporting patients with community resources
  • Reducing re-admissions to the hospital and emergency room

 

 

Meet | KATHY WORK, RN

Kathy recently joined CHI as an Ambulatory Care Manager. She is a resident of the Monterey Peninsula and offers an extensive background in Home Health Care and Emergency Nursing. In the community practice setting, Kathy performs care management services for complex/high-risk patients. CHI defines this as the management of a complex acute and/or chronic medical condition, in which medical and/or socioeconomic barriers impede adherence to a medical treatment plan/goal.

Always eager to expand her knowledge, Kathy truly enjoys interrelating with her peers and the medical practice staff. So it comes as no surprise that, when asked about what she likes most about her involvement with care management/clinical care coordination at CHI, expanding her post-acute care knowledge and experience through professional interactions is high on her list. Another of her favorites: the ability to support patients who are committed to improving their health and well-being.

Kathy appreciates how Essette workflow tools simplify the process. She says she really values being able to, ”choose the appropriate assessments and, even before I call the patient, to enter data available in the medical record. This allows more time during the call for questions requiring the patient’s attention.” Not only does this make the call more efficient, but Kathy feels more confident that, when she has a 360 view of her patient, she can facilitate a complete care plan. Having goals embedded in the assessments also helps her formulate the care plan more quickly. ”Being able to schedule appropriate tasks while the information is fresh in my mind is a big plus—it helps keep the case on track. Especially during those first few weeks, when it always seems to be the busiest!”

Kathy also appreciates that, during subsequent contacts with the patient, she has the ability to update the care plan—and to schedule the next contact, reminders and any follow-up needs.

Somehow, Kathy even finds time to volunteer with the Pacific Grove Hyperbaric Chamber, treating injured divers and patients suffering from carbon monoxide poisoning.

 

a9640886-261a-4923-b168-469a20ae09d5Meet | HOLLY RODERICK, LVN

Holly has been active in the Central California medical field for more than 12 years, working and learning in the acute care setting, which included the OR, ICU, ER, Med Surg, Peds and OB. Before becoming a LVN, she focused her energy in Admitting, Medical Records and a private oncology office. She has been part of the Care Management Team at CHI since May 2014, when she took on a new role as Clinical Care Coordinator (CCC). It is a significant role and one that many healthcare communities still try to define and implement, since its primary functions surround Transitions of Care (TOC).

CHI defines TOC as ‘the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.’

The tasks, goals and interventions established for Holly’s role focus on moderate-risk patients. She depends on Essette’s user-friendly platform to effectively manage her caseload and says it helps her with time management, documentation accuracy and prioritization. “I love the ‘To Do List’ feature and the case navigation tab. Those items help keep me on track and ensure that I have touched on everything in my patient’s chart. Essette has really brought an all-inclusive form of documentation into the Care Management world. It’s really great!”

Holly’s lifelong passion of caring for others and serving the communities around her is evident. When asked what she enjoys most about being involved with the care management/clinical care coordination team at CHI, she responds, ”My favorite part is participating in and watching our program grow and evolve into one that helps care for the entire community.  I love that we are given the opportunity to provide resources, manage and make a difference in the health of our most chronically ill patients and their families.’

When she’s not collaborating with the team at CHI, she loves spending time with her husband and daughters. She lists traveling, cooking and being outdoors as some of her favorite pastimes.

 

Thank YOU!

Thank you, Kathy and Holly! We appreciate your willingness to be Case Management Week ambassadors. You and your team demonstrate that care managers are not ‘JUST’ nurses and that Essette is not ‘JUST’ software.

 

About Essette

Dedicated to a business model focused on integrating healthcare’s needs with technology, creative thought, and integrity, Essette is committed to making a difference. Essette™ (pronounced eh-SET) web-based care management software offers an incredibly efficient, user-friendly, high-performance platform specializing in partner integrated solutions. Learn more about EssetteCM™ and Essette’s other simple software solutions by visiting www.essette.com, or through community@essette.com.