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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

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