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Care management program helps patients navaigate health care system

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Care management program helps patients navaigate health care system

Hospital news | Friday, August 28, 2015

Contact: Thomas Hottman

LEFT: Dawn Rezac with her husband, Karl, said the Sky Lakes Outpatient Care Management Program helped her to not feel so overwhelmed navigating the health care system.

Care management program helps patients navigate health care system

After cleaning up after breakfast one morning earlier this year, Dawn Rezac started "feeling weird."

"I just knew something was wrong," she said. "I guess my oxygen level dropped to 80 percent."

She found that out after her husband, Karl, rushed her to Sky Lakes Medical Center, where she stayed for four days.

Dawn, a writer, works at home, and Karl is retired, and before the Affordable Care Act went into effect, neither had health insurance. They waited until the last minute, or January this year, to sign up for coverage through the state healthcare exchange.

But until Dawn ended up in the hospital, they knew very little about the details of their new insurance, what was covered and what wasn't, or how to navigate the health care system in general.

Because money is tight, both Karl and Dawn have a few health issues they had ignored, and they knew needed to be addressed.

"The whole process was overwhelming," Dawn said. "It was basically Karl and I having this life-changing event."

But when Dawn's oxygen level dropped, she was also dropped as a patient by her previous primary care provider soon after. She returned to the hospital about a week after receiving treatment for her oxygen level because her blood pressure was "out of control," she said.

But her doctor thought she was either drug-seeking or self-diagnosing, she said. Because of her oxygen loss, Dawn now has damage to her short-term memory, and sometimes smells phantom smells.

"Sometimes we'd go to the hospital two or three times a week because things happened," Karl explained.

She's now a patient at Cascades East Family Practice, she said, and was connected with the Sky Lakes Outpatient Care Management Program.

Through the care management program, the Rezacs connected with community health worker, or CHW, Dawn Wallace, who has helped them navigate insurance, offer education about when to go to the hospital, and more.

"She has been an absolute jewel," Dawn Rezac said of Wallace.

With Wallace's help, Dawn now doesn't feel so overwhelmed by the health care system, and has her questions answered, she said. Before, she had an idea of what needed to be done to start improving her health, but didn't know how to do it.

Wallace helped Dawn obtain a letter from her insurance provider, the Oregon Health Plan, to attend low-impact water aerobics classes at the YMCA for free, for example. Wallace also tags along to counseling sessions, where Dawn discusses childhood abuse, as well as other doctor appointments.

Having Wallace available to take Dawn to doctor appointments has freed up time for Karl to work on his own health — he has a pacemaker, which needs to be replaced soon, so he's working to improve his cardiovascular health.

"As a whole, it's made us stronger," Dawn said of the program.

Making improvements

While Dawn Rezac still struggles with short-term memory loss, and has difficulty sleeping through the night, she's glad she has Wallace on her side.

Wallace has helped Dawn establish routines to help her throughout the day, which alleviates some of the problems that come with her memory loss, and helps her make lists of things to discuss with her doctor.

Karl feels like he and Dawn know the healthcare process better now, and that they can reach out to Wallace with any questions.

When it comes to navigating changes to the health care system, Dawn Rezac feels doctors and other providers receive a lot of training, but the general public misses out on education. That's why the care management program is important, she said.

"I think in this community, there is a lot of need for what they do," she said. "There's such a need for that here. People don't know what's available to them. I still don't know what all is available, but I'm learning."

Dawn has very clear goals of what she'd like to accomplish with her health, including losing weight.

"It's wonderful knowing that I'm at least getting into the solution," she said. "That in itself is making me feel a lot better about everything."

About the Outpatient Care Management Program

Dawn Wallace is one of four community health workers in the Sky Lakes Outpatient Care Management Program, which started last year under the name non-emergency medical transpiration, said director Molly Jespersen. The name was changed to reflect the full scope of the program.

In addition to the community health workers (CHW), the staff also includes a nurse and certified nursing assistant, as well as a new program supervisor.

Jennifer Little, who previously worked for Klamath County Public Health, started as the program supervisor this month, working to close some of the gaps between inpatient and outpatient care for Sky Lakes and identifying ways to make the programs and processes more efficient, Little explained.

CHW Cristal Neri described her role as helping clients get needed care, and navigate "day to day." Some of that assistance can be "pretty basic," such as helping establish primary care, advocating for them with insurance companies, and offering education on things such as proper prescription practices, she explained.

The process

For Neri, the process of connecting with a client starts out casually. She meets people in their homes, talks through ice breakers with them, tells them what the program is about, discusses some of their health concerns, and if the client is open to it, can conduct a risk assessment to get a clear picture of the client's health, including all aspects such as environment, mental and social health.

"You want them to feel that you're here for them," Neri said, adding that many of the clients need someone to believe in them and support them. The relationship is more of a friendly, or neighborly, one, than of a healthcare provider and patient, she said.

Building a trusting relationship is important, Jespersen agreed.

Neri said she focuses on what a client's biggest need is first, and then works with them to create an action plan to address that main problem, and other health-related issues they may have.

Since the program started in September 2014 with Cascade Health Alliance patients, it has expanded to include open-card Medicare and Medicaid patients as well, Jespersen said. The program has more than 150 active clients, and has received more than 800 referrals in one year, she said.

While some clients just need short-term assistance, such as help advocating to their insurance, others may need support from a CHW for up to a year.

Navigating services

Doug Tofell, the program's lead CHW, said the easiest way to explain his role is as a navigator. CHWs offer a bridge of support to help clients figure out how or where to go do things, or how to prepare for a doctor's appointment, he said. The term "navigation" seems to fit, Tofell said, because much of his work involves pointing people in the right direction.

Dawn Wallace has a slightly different view of her role for clients.

"I bring hope to people that don't have any hope," she said, adding that she sees herself as their cheerleader.

Many of Wallace's clients are women, and she's seen drastic changes in their self-confidence through the program — they feel more empowered, and feel able to stand up for themselves, she said.

"We give them the skills to empower themselves," Wallace said.

Like Dawn Rezac, many clients have felt overwhelmed, Jespersen said.

Clients may have lost some self-sufficiency skills and motivation, Tofell said.

"I think they've lost confidence in making decisions themselves," he said. "They lose hope in themselves, in their health, their environment."

Above: The Sky Lakes Outpatient Care Management Program staff includes director Molly Jespersen, bottom left, community health workers Dawn Wallace, bottom middle, Cristal Neri, bottom right, Doug Tofell, top left, and Brittany McCoy, top middle. Program supervisor Jennifer Little is pictured at the top right.

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