Care Team of the Southwest teaches residents to self-manage

Courtesy of Jane Looney

San Juan Basin Health Nurse Navigator Helen Joline takes client Juan Romero’s blood pressure during a home visit.

Juan Romero is a fourth-generation Southwest Coloradoan who proudly traces his family history back to the 1500s.

Last year, Romero was told during a disability health screening to go the hospital right away because of immediate concerns about his high blood pressure and cholesterol. When he arrived at the front desk, he was told to go to the emergency room.

Adamantly refusing to incur unnecessary debt, Romero finally got a helpful answer – he was referred to Helen Joline, a Nurse Navigator with San Juan Basin Health’s Care Coordination Team of the Southwest.

Looking back, he says, “I didn’t know what kind of help I needed or which way to turn.” Romero is now the healthiest he has been in a decade, and he credits his Nurse Navigator.

Joline is one of three Nurse Navigators on the team who ensures a continuum of care. While each focuses on an age range, they can extend services to other family members when appropriate, thereby addressing the family unit as a whole. So not only was 58-year-old Romero assisted by Joline, the designated “adult nurse navigator,” but so, too, was his 92-year-old mother.

Nurse Navigators worked with more than 400 referrals last year. These are primarily people identified as having two or more chronic diseases, one of which can be behavioral health, and a non-medical barrier to care such as transportation, day care, lack of insurance or language. Along with high blood pressure, for instance, Joline discovered Romero had diabetes and no transportation.

Entering its second year, this locally funded pilot model was tasked with the dual goals of producing better health outcomes and decreasing cost. CCTSW accomplishes these by: (1) decreasing ER visits; (2) decreasing inpatient readmits; and (3) decreasing duplicative costly imaging services being ordered from multiple providers.

“By sharing our data with partners, we can target duplicative services and allow clients to move around between providers more effortlessly, safely and effectively,” Vanessa Boyd, Care Coordination Services manager, says.

CCTSW is a private/public partnership that includes Rocky Mountain Health Plans, Mercy Regional Medical Center, Pediatric Partners of the Southwest, Axis Health System and La Plata County. Representatives from these agencies and offices, along with other supporting partners, meet monthly as an oversight committee through the Southwest Area Health Education Center.

Through a client-centered approach, clients formulate and follow a care-management plan, they establish a medical home that addresses their needs, and they know how and when to access care.

“Our goal is getting clients to ‘graduate’ to a level of care that indicates the person is self-managing,” says Boyd.

Both Joline and Romero agree that he has more than merely ‘graduated’. He’s content, healthy and able to take care of his mother. “I’m at a place where I can cope with life’s surroundings,” he says.

He credits Joline with taking charge when he was lost.

“She guided me – she really is a navigator,” he said.

For more information, call Vanessa Boyd at 335-2005.

Jane Looney is the communications director for the San Juan Basin Health Department.

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