Combining high-tech and high-touch with care guides

The previous blog post focused on how Minneapolis-based HealthEast applied data and analytics from Optum One to get great care management results. This final blog in the three-part series will show how care management is making a difference in patient lives.

One relatively new element to care coordination that HealthEast put into practice was certified community health workers. HealthEast calls them “care guides.” These care guides are non-clinical professionals with a skill set focused around the needs of a particular community. HealthEast care guides help the organization determine which patients would benefit from additional care coordination.

“We focus on the patients’ pain points―it’s up to the patient to determine what’s important,” said Maggie Sparks, a care guide for HealthEast’s Maplewood Clinic. “We always start with a goal setting visit and try to understand what has worked or not worked in the past. At our clinic, we focus on lifestyle changes. Sometimes, the patient’s goal might not be a scale change, but instead just increasing a patient’s self-awareness.”

Care guides help facilitate discussions between primary care providers and the riskiest 20 percent of patients with diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). HealthEast employs Optum One’s predictive risk modeling module to identify these patients. During these discussions, physicians educate the patients about the benefits of receiving additional care coordination support. And on a monthly basis, each clinic holds a “care conference” to review the status of those patients currently working with a care guide as well as review other high-risk patients for future enrollment.

Sparks said that one of the most satisfying parts of her job is seeing patients overcome barriers and meet their goals. One patient assigned to Sparks was an older woman who had become morbidly obese. Her condition had deteriorated to the point that she developed chronic back pain that made it nearly impossible for her to walk. The patient’s legs would shake violently when she attempted to move. She was severely depressed by her condition and told Sparks that the idea of exercising scared her.

Through Sparks’s coaching and use of motivational interviewing, the woman agreed to join a gym that offered pool-based exercise classes. The patient also worked to limit her intake of sugar. As the months progressed, the patient was able to replace fatty foods from her diet with fruits and vegetables. Less than a year later, the patient has lost 40 pounds and her symptoms of depression have reduced dramatically.

This woman’s journey to wellness is just one of many examples of how HealthEast’s medical home program has made a difference in the health and wellness of their chronically ill patients. Similar to other delivery systems, HealthEast previously had difficulty monitoring patients with chronic illness across the continuum of care due to disparate data systems. With Optum One, HealthEast now has a single source of truth for identifying high-risk patients and tracking care coordination outcomes.

By combining its focus on patient-centered care with the care coordination-enabling data and technology of Optum One, HealthEast hopes to continue to transform both its own care practices and the health of its community.

To download the full HealthEast case study, click here.

Leave a Reply