You’re a patient at one of St. Joseph Healthcare’s primary care practices. Now, imagine these scenarios:
- Your provider says you need to be hospitalized and will then transition to a rehabilitation facility.
- You were recently diagnosed with a chronic condition and must learn to manage it.
- You need to arrange for home health or hospice care but don’t know where to begin.
- You’ve been prescribed a specific medication but can’t afford it.
Members of St. Joe’s care management team will be there, in these instances and all sorts of other often overwhelming scenarios, acting as advocates for primary care patients. The care management staff is a small but mighty team of six. They are all registered nurses who, by design, have complementary clinical experience, which empowers them to meet the unique needs of diverse populations. Jessica Taylor, director of care management, shares,
“Our focus is three-pronged. We take a proactive role in transitioning patients from one care environment to another,
educating patients with a chronic diagnosis on how to effectively manage their condition, and supporting any other care need a patient may have to help ensure a positive outcome.”
Another significant priority for the care management team is building relationships with community resources. They then connect patients with these resources to help them improve their overall health. Those local resources include the Good Shepherd Food Bank, Maine Federation of Farmers’ Markets, and Eastern Area Agency on Aging.
There are several aspects of the team that distinctly differentiate them from other patient support services. At St. Joe’s, any hospital employee may refer a patient. For example, if a patient
shares with a receptionist that he or she is having issues with transportation to doctor appointments, the receptionist is encouraged to refer the patient to care management for help.
In addition, patients have their care managers’ direct phone numbers and can easily reach them without working through office staff. Finally, during the COVID-19 crisis, the care team has been particularly supportive of vulnerable senior patients who have been afraid to leave their homes but have needed food, prescriptions, and even toilet paper. Taylor proudly adds,
“We like to say ‘we work the mission’ in the community and with compassion. Every day, our job is to walk beside our patients — whether it’s at an office visit, home visit, or wherever they’d like to see us — and connect them with the care, support, or referral they need.”
For more information:
This story originally appeared in the July/August 2020 edition of Harvest Magazine, you can find the original story here: “St. Joseph Healthcare’s Care Management Team Works the Mission”.