Connecting Consumers Presented by: Scooter Gates, MHA/Care Manager Team Coordinator RiverStone Health Clinic Billings, MT 10.27.2016

Care Management in our clinic Medical Model This “team” varies but often will include Medical Provider, Nursing, Dietician, Diabetic Educator, Behavior Health and Care Management Care Management in our clinic Our goal is to offer Care Management services to our patients with identified needs

Care Management is a integral part of the team in providing support services, such as: Focus on whole person care Assisting patients with ways to manage their health needs Non-Clinical, hands on support – addressing social factors that ARE barriers to their health goals Being a “go to” person for patients and staff

How to meet with patients that have identified needs? Medical Team member asks Care Manager to meet with patient Patients express need during check in and staff alert Care Manager that patient has asked for assistance Review of Social Drivers that may affect their health form for any areas of need Daily review of patients listed as self pay, Care Manager lets team know

What works? Having a defined name and sticking with it! Being pro-active and informing other team members that patient needs to be seen by Care Manager Follow up with Team and give brief review of needs addressed, or expressed Building relationship with the Team AND patients that Care Managers can be relied on Thinking “outside box” regarding what can a Care Manager do and assist patients with

Challenges? Balancing the Clinic “rooms” and getting to see patients without disrupting flow Can only be in one place at a time Ongoing staff education about Care Management’s role

Where is Care Management going? Continue to grow and improve services regarding High Risk Case Load Work toward a more medical model of Care Management Services (Whedon Program, Advanced Directives) Will there be a need for home visits Determine role of “Outreach” for Medicaid patients not engaged in care Determine role for Insurance Enrollments

How will we get there? Look beyond the traditional Care Management lens – Management input Recognize potential of team Document Productivity – data talks! (added minutes tracking on Care Plans) Remain open minded

I alone cannot change the world, but I can cast a stone across the waters to create many ripples. Mother Teresa