Until you have cared for a sick child, spouse, friend, or loved one, you may not truly understand that health care is not ‘one size fits all’. Although a diagnosis may be the same, never is the circumstance, nor the outcome. The Care Coordinators at San Juan Basin Public Health (SJBPH) experience this truth daily as they work to serve a wide range of individuals with myriad health concerns, many of them with complex needs.
Loosely defined, care coordination is the organization of a client’s activities related to their care, including the sharing of information among those involved in providing this care. A key aspect of this type of care is its client-centered strategy, taking into consideration the individual’s needs and preferences, which are shared with those involved in each person’s case. The goal is safer, more appropriate, efficient, and effective care for each patient.
Care coordination is about reducing barriers that many individuals experience as they try to navigate the often-times confusing healthcare system, but equally about addressing more practical gaps such as transportation needs, food insecurity, or language barriers. Care Coordinators can act as a liaison between a client and multiple providers to improve communication, as well as helping to ensure that a client has food on the table. This means taking each individual’s entire health picture in mind when taking steps to meet their needs.
One local example of care coordination is Marsha, a single, fifty-year-old woman living in rural La Plata County. At 40, Marsha battled cancer while working full-time and caring for her grandchildren. Now, ten years later, the cancer has returned and Marsha has relied on care coordination to help her manage this challenge. She needed help with coordinating a variety of appointments, understanding the information coming from several care providers, and figuring out how to manage financially while able to work only part-time. The SJBPH Care Coordinator connected her to a variety of community resources including food assistance, and helped her apply for long term care Medicaid. Additionally, the Care Coordinator assisted with scheduling doctor’s appointments, and helped get answers to the questions that she had regarding her treatment. As Marsha’s health needs persisted, her Care Coordinator helped connect her to the providers and resources that she needed to stay healthy enough to care for her grandchildren, and to continue to work as much as she could.
As in Marsha’s case, care coordination often includes developing a care plan to manage each client’s chronic conditions, and associated health challenges.The care plan also helps a client with medication management, often an overwhelming task for individuals with complex health issues.
At San Juan Basin Public Health, our multidisciplinary team of Registered Nurses, a Dental Hygienist, and Care Coordinators strive to improve the health outcomes of local community members who face barriers to care. Through education, outreach, navigation, and collaboration, our Care Coordinators assess the needs of clients of all ages and serve those with a variety of medical complexities, social barriers, and healthcare needs. Through this important program, SJBPH Care Coordinators hope to connect the dots, and create clarity in a not-so-linear health care system, to support everyone we serve in reaching their highest potential of health.
While many of our Care Coordination patients are those who qualify for Health First Colorado, our foundation is as a Community Care Team, and our model is designed to provide access, guidance, and advocacy to anyone who faces barriers to health care and resources.
Altogether, the activities of SJBPH’s Care Coordination Program can make a real and meaningful difference in the health of the local community members they serve – and can even save their lives.