“How am I going to get through today?
That’s the question on the minds of many patients Roger Hershberger encounters as a social worker with the Beacon Care Coordination team, a group of clinicians that works to improve the health of chronically ill patients of the Beacon Health System.
“When you first get that diagnosis, that’s scary as heck,” social worker Ellise Moore said. “When you get a new diagnosis, that changes your whole world. It’s a foggy mind-frame.”
It’s Care Coordination’s responsibility to help the patient work through what comes after the diagnosis. This could mean anything from assisting the patient in finding a prescription plan that works for their finances to setting up stable housing, or even addressing food insecurity – especially as many patients must follow specialized diets.
“A lot of them are living day to day,” social worker Deja Johnson said.
In and out of Beacon’s hospitals, the Care Coordination team helps patients continue to manage their care even when they’re at home. The team puts a face on healthcare that isn’t necessarily dressed in scrubs.
The Care Coordination team is made up of around 20 people, including an inpatient nurse navigator team, an outpatient team of nurse care coordinators, licensed clinical social workers and community health workers, as well as an outpatient heart failure transition clinic.
Describing the impact of socioeconomic challenges on the patients they serve, team manager John Bruinsma explains that ER and hospital visits are often the result of more than just one acute event. “All the things that make a person healthy don’t necessarily happen in the four walls of a hospital.”
“Often when you get to a patient’s house, you find that their medical need is not the most pressing issue,” Hershberger said. “They might not have food at home, but they didn’t tell that to a nurse or doctor.”
Bruinsma says his team often finds solutions that patients don’t know about or don’t know how to access.
“For so much of their life, they’ve been living in ‘how do I do this?’ mode,” says Ellise Moore. “Sometimes they can’t read or can’t fill out paperwork.”
Bruinsma describes the team as the spokes on a wheel, or a bridge that connects them to the right supports in the community. Hershberger, Moore and Johnson are careful to note that the patient is at the center of their own success.
The needs vary person-to-person. But the team’s goal is not to do everything for the patients they encounter. Empowering the patient to manage their own health outcomes is at the core of the team’s mission. “If they’re at a point where they’re not fully independent, we try find a place to help them be as independent as possible.”