Published in Moms & Dads Today, May/June 2015
Care Coordination: Putting Patients First
For most of us, interactions with health care providers tend to come at
times when we aren’t at our best. Maybe we’re sick. Or stressed.
Anxious. Or depressed.
And that’s to say nothing of the ordinary complexities of health
care itself. Various doctors, specialists, nurses, technicians, procedures,
locations—the system that exists to help us can sometimes be difficult
to navigate.
It is because of the needs that arise at this intersection of patient and
provider that the idea of care coordination was born. According to Aaryn
Ackley, a care coordinator at St. Luke’s Mariner Medical Clinic
in Superior, care coordination is the vital link that helps people get
the care they need—and in the way they need it.
“Care coordination is all about taking into account all the aspects
of health care—care for the whole person—and making sure they
are all integrated,” said Ackley. “It is a relatively new
addition to the health care field. Care coordinators at St. Luke’s
primary care clinics take on some administrative duties previously done
by physicians and nurses so these providers can fully focus on patients.
Care coordinators also provide a huge amount of emotional and practical
support for patients and families who may be dealing with complex medical
needs that involve lots of touchpoints within health care.”
She added, “Care coordination is absolutely the future of health
care.” And, through an initiative for primary care clinics, St.
Luke’s has already stepped into that future for the benefit of patients
using the ‘Health Care Home’ approach.
Health Care Home
According to the US Department of Health & Human Services, care coordination
“involves deliberately organizing patient care activities and sharing
information among all of the participants concerned with a patient’s
care. This means that the patient’s needs and preferences are known
ahead of time and communicated at the right time to the right people,
and that information is used to provide safe, appropriate and effective
care to the patient.”
Krista Harju, children’s mental health care coordinator at St. Luke’s
Pediatric Associates, says this definition squares with the initiative
the state of Minnesota is implementing to advance care coordination in
clinics around the state. According to Harju, this approach in Minnesota
is called a ‘Health Care Home.’
“The name is a little confusing, because some people think it is
referring to a specific place or building,” said Harju. “Health
Care Home (or HCH) is a team approach to your health care, that may include
a care coordinator, if your needs are more complex. HCH clinics operate
as a team, providing care coordination. Not every patient will have a
designated care coordinator, but every patient can get coordinated care
through this patient and family-centered team approach. It truly puts
the person at the center of his or her care.” Harju added that all
St. Luke’s primary care clinics are either certified by the Minnesota
Department of Health as a Health Care Home or in the process of obtaining
their certification.
A real-world example
Harju, who works with children and their families, gives this example of
the practical difference that care coordination can make. “Let’s
say we have a single mom who has a young teenage son. Maybe he is overweight
and is dealing with diabetes. In addition to his diabetes, however, he
is also depressed and not really engaging in school. In the past, that
mother would have to deal with all of those issues on her own. And while
the health issues would seem to be a priority, there is so much more going
on with her son that could be affecting his health.”
Now, take that same scenario, only this time, a Health Care Home coordinator
at a St. Luke’s primary care clinic is integrating the patient’s care:
“After the physician refers this young man to care coordination,
the care coordinator is alerted that he is coming in for an appointment
tomorrow about his diabetes. Before he arrives, we’ve reached out
to community resources that can help him deal with his depression. We’ve
lined up a dietitian to help him control his weight. And, after getting
consent from his mom, we’ve reached out to the school to help him
in his classes. His care coordinator is even making sure he has access
to healthy foods and exercise options.”
All of these services, says Harju, are actively managed by a care coordinator.
“The care coordinator can be the person to help the patient or family
navigate through the health care system, and can be a continuous point
of contact for those patients with more complex needs. Care coordination
may include a care plan, contact with community service providers, and
contact with the care coordinator as needed,” she said.
Care coordination is a relatively new concept in health care, but according
to Ackley, it is a discipline that is already making a huge difference
for patients. “Every week, I get cards, letters—sometimes
even chocolates—from patients who are just so happy to have an advocate
working with them to get the care they need. It is a hugely rewarding
job.” She added, “Every night, I come home and tell my husband:
‘I just have the best job.’”
BELOW: Care Coordinator Aaryn Ackley helps a patient