How care managers use human connection to deliver proactive care

“The knowledge I've soaked up and taken action toward — based on my care manager's feedback — I believe has extended my life,” a Nevada patient recently said after a survey. ?"Without this program, it would be impossible for me to navigate my health needs.”??

At Intermountain Health, we’re taking a proactive approach to health care — partnering with individuals to keep them healthy. When patients need care, care managers are an important part of the team.

“When you improve the patient's experience and quality of care, they're motivated to become healthier and do what they need to do to optimize their health,” said Kristel Agustin, RN, the nurse care manager who received the survey feedback.??

Kristel supports several clinics in Las Vegas, helping individuals return to health after an acute illness or manage chronic conditions. The relationships she builds through regular touchpoints help patients set and progress in their health goals.?

One patient would go to the emergency department whenever they had health issues or symptoms without calling anybody from the clinic. Kristel started regular conversations with them about taking the right medications and seeing a specialist. She also encouraged them to call the clinic or her with any concerns.??

“I followed up for over a year, and they stopped going to the emergency department for little things and developed the routine of calling the clinic,” she said.??

Kristel usually works with around 70-80 individuals at a time and tries to follow up with each one every two to four weeks. She tells them, “We want you to be better. We can't fix everything, but we can give you the tools we have and tell you what we know.”?

At Castell, care management is a way to reach out to people?

A Spanish-speaking pregnant woman reached out to Melanie Smith, RN, nurse care manager at Castell, for help. She told Melanie that early in her pregnancy she found out she had cancer. Fear set in — about the diagnosis and whether she’d be able to care for her new baby. The fears kept her from returning to the doctor. Melanie searched the woman’s record, found a referral to which hadn’t been used and helped schedule an appointment. There the expectant mother learned she didn't have cancer but abnormal cells that would need follow-up. She was so relieved she didn’t have cancer and delivered a healthy baby soon after. ? ? “I've seen care management improve patient outcomes,” Melanie said. “Here was someone who was feeling down and then found some hope and had her health needs met.”?

Melanie, a Spanish-speaker herself, appreciates when she can speak with patients in their primary language. Melanie helped the woman follow up with resources available in the community and a further medical appointment.?

“Care management is a way to reach out to people, help them solve some of their problems affecting their lives, and give them hope if they're in a hard situation with a chronic illness or social determinants of health needs,” Melanie said. “When I do that initial call. I'm not only assessing their needs, but I’m also learning who they are as a person.”?

Patients — like the one Melanie helped — can self-refer to care management, be referred by physicians and advanced practice providers (APPs) or be connected to care management at discharge from the hospital through a transition of care process.??

Castell’s care management team, which provides complex care management for clinics in the Canyons Region, also actively reaches out to individuals to see if they’re interested in care management, especially those managing multiple health concerns or have visited the emergency department frequently.?

“Care management helps to empower a patient with information, knowledge, and resources so they can self-manage their conditions and understand when and how to seek assistance when they need it,” Melanie said. “Through continued follow-up phone calls, the questions I ask, and helping them solve a problem, I show I really care about them. It's the interest you show in a person that matters — that you truly want to help them.”?

If she recognizes social needs in her assessment, she’ll make a referral to Castell’s social work care managers, who can help the individual find answers to those social needs impacting health.?

A collaborative approach creates a network of support that care managers can use to help patients manage their complex needs. This includes partnering with Select Health, Intermountain’s insurance product.?

“We’ve built processes that allow us to collaborate effectively with both Select Health and the hospital care management teams,” said Barry Boyce, ACM-RN, Castell senior director of ambulatory and community care management. “Part of the reason for that is our National Committee for Quality Assurance (NCQA) accreditation for complex care management, which focuses on transitions of care.” ??

At Select Health, care managers improve access to care?

Castell and Select Health care management teams work closely to meet the varied needs of Select Health members.??

“When a patient has a lot going on, a Castell care manager may ask, ‘Can you help connect them with in-network providers and resources,’” said Tamara Smith, RN, nurse care manager at Select Health. “Where Castell has strong connections with the primary care providers, we can assist members with authorizations for coverage.”?

But Select Health nurse care managers also partner in clinical ways.?

Tamara worked with a hospice care manager to help a member with terminal cancer who was being discharged from hospice care. The individual recently moved to the state, was homebound, didn’t have any established providers, and didn’t know how to access the services hospice provided — a hospital bed, medications, and medical equipment.??

Tamara partnered with the Castell House Calls team, which provides care to individuals in their homes. They worked together to meet the member’s needs, establish care, and arrange nutritional support from Meals on Wheels.??

“The member called me tearing up when the Ensure arrived at her doorstep. She said it was such a miracle,” Tamara said.?

Where there are needs related to the social determinants of health, Select Health care managers partner with community health workers?who can call or text the member, do in-home visits, or meet the member in person to connect them to community resources.?

“The biggest thing is meeting them where they're at, not trying to force them into a goal,” Tamara said. “Some of our members can't access care because they don't have transportation, a place to live, or enough food. To that I say, ‘Let's get through those barriers first to then help you access and coordinate the care you need.’”??

"When we practice proactive care, we improve patients' experiences, helping patients avoid chronic disease and major health problems," said Dan Liljenquist, chief strategy officer. "With it, we improve the caregiver experience, empowering you to be a more proactive partner alongside your patients."?