Department Spotlight: Community Care Management
June 30, 2023
Now, put yourselves in the shoes of someone who may not know where their next meal may come from, someone who may be homebound and not have access to transportation, someone who may be on a fixed income, someone facing homelessness or even someone who may be struggling with substance abuse issues. Getting healthy – and staying healthy – comes with a unique set of obstacles, or social determinants of health, for these patients to overcome. Inequities around social determinants and health behaviors have an outsized impact on patient outcomes, and social and economic factors make up 40 percent of those inequities.
This is where the caring and compassionate community health workers, social workers and registered nurses that make up Renown’s Community Care Management (CCM) department rise to the occasion. As the need for resources grows in northern Nevada, these dedicated team members fill those gaps and ensure every patient feels prepared, educated and equipped with everything they need to continue their care journey and live a healthy, fulfilling life.
Defying Disparities
When our community at risk faces healthcare disparities, it can create complications in each patient’s life that may keep them from addressing their healthcare needs and affect the likelihood of them being admitted or readmitted to the hospital or continuing to struggle with their care management – but not on CCM’s watch. Whenever possible, the CCM team steps in to provide critical resources, education and care journey guidance for any patient that finds themselves in need.“In the simplest terms, we do outpatient case management with vulnerable populations,” said Barb Mader-Scherrer, Director of Community Care Management. “It may be anyone from elderly people who need help managing chronic diseases, to patients experiencing homelessness who are being discharged from the hospital. We work with folks who are facing all sorts of challenges.”
Several roles make up the CCM department, including Community Health Workers. These team members are the resource experts, on the front lines of helping educate patients and supporting them as they navigate through the facets of their care. Their main goals? Avoid admissions and readmissions to the hospital and continue to meet their unique goals.
“I have the pleasure of working with patients who may need financial help, transportation help or even help utilizing the food pantries in our community," added Steve Arm, Community Health Worker. “We help patients navigate healthcare and social services, address social determinants of health, encourage self-efficiency and provide general health education for many chronic conditions. We also provide home visits for our patients who need extra support.”
“The day in the life of a Transitional Community Health Worker is to outreach to the patient while being admitted, do a bedside assessment, complete the social determinants of health evaluation and provide any resources needed to avoid readmission,” added Sherrie Skaggs, Community Health Worker. “Our main population is Medicaid, and many are homeless and financially challenged. As needed, we continue to ensure that follow-up is completed, and all needs and goals are met.”
For those learning to cope with their condition and needing hands-on help especially after discharge, the CCM Social Work Care Coordinators take on this complex aspect of the healthcare journey. These individuals provide support and intervention for Renown patients facing a chronic, behavioral health or substance dependency condition to improve their overall quality of life beyond hospital walls, developing a strong framework to build a long-term healthcare plan.
“As social work care coordinators, we help connect patients with mental health resources, welfare programs, community support, caregiver burnout resources, placement for loved ones with terminal illnesses and much more,” said Irina Osmolovska, Social Work Care Coordinator. “Requests that come to us run the gamut of homelessness, family crisis, food insecurity and even situations where a patient has no electricity for their life-saving medical equipment. We receive challenging requests and are always ready to go above and beyond to advocate for our patients.”
Possessing a profound understanding of the delicate balance between medicine and the patient spirit, the CCM RNs help bridge the gaps between the hospital or primary care practice and post-discharge settings, ensuring a smooth transition for patients as they move from one healthcare setting to another. With their expertise in care coordination and patient education, these RNs help enhance patient outcomes and promote continuity of care.
“Our group is responsible for making discharge follow-up calls to patients who have Medicare, as well as scheduling their hospital follow-up visit if needed,” said Vanessa Alford, Consulting RN. “The goal is to have every patient see their primary care physician within 14 days of discharge for continuity of care and to prevent readmissions. We also screen patients for eligibility for Chronic Care Management or Personal Care Management. In addition to setting up the patient for follow up, I review each patient's medications, answer any questions they may have about their medications and health conditions.”
As another important part of unpacking the intricate web of social determinants impacting health, CCM RN Care Coordinators have the extraordinary opportunity to extend this department’s compassionate care beyond the boundaries of the traditional in-office environment. Whether it be through virtual connections, heartfelt conversations over the phone or in-person encounters outside the hospital, RN Care Coordinators create holistic and enduring plans of care for individuals facing chronic challenges – including behavioral health issues and chemical dependency struggles – at every stage of life.
All in all, the CCM department recognizes the interconnectedness of physical, emotional and social well-being for all patients, fostering a sense of wholeness and empowerment to ensure they continue to meet their goals and live healthier, happier lifestyles.
“Our team has a holistic approach to our work,” said Barb Mader-Scherrer. “We look at the whole picture. What are the medical things we can do for this person? What education do they need to help them manage their condition? Do they have food in their house? Do they have a safe living environment? Are there substance abuse issues? Do they need help in managing their medications?”
“My 18 years of experience in various areas of hospital nursing and home health have given me the knowledge to serve patients in our community holistically, and I feel good about what I do,” added Vanessa Alford. “I hope that I am able to lessen the load on the medical assistants and providers in the clinics so they can focus on their patients on site.”
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Lifelong Impact
With a deep understanding of the physical, mental and social complexities of the health system and managing a chronic condition, especially as a patient that identifies as a member of a vulnerable population, CCM ensures that each patient’s care doesn’t end when they exit Renown’s doors. Quite the opposite – this team develops close relationships with their patients and develops tailor-made plans, offers education and self-management strategies and coordinates a wide range of resources to enhance their well-being.
“Our goal is to help patients live a better quality of life in the face of chronic diseases through education, assistance and support,” said Christina Bankert, Supervisor of Community Care Management. “We have our patients from a few weeks to several months, so we get to know them, understand their needs and keep them home and healthy – and out of the hospital.”
“We continue daily to support and guide our patients through all the adversities they face and reassure them that we are here for them,” added Steve Arm. “They do not have to face the challenges alone.”
Feeling lost within the health system can drive a patient to not follow through with their care, especially when they are facing certain disparities. However, when CCM team steps in, follow-through is not only a goal – it's a promise. And they are here to clearly communicate and guide them every step of the way.
“I am glad to work in the program that helps the vulnerable population in our community,” said Irina Osmolovska. “Some of them get stuck in the limbo of the complex healthcare system, and it makes me proud to be able to help them navigate this complexity.”
“Communication is a key component when providing patients with quality care,” added Steve Arm. “It is my belief that if the patient feels supported in all areas, then the patient thrives and does better with follow through themselves.”
CCM runs several programs to help set patients on the right path to health and healing, including:
- Transitional Care: Our community health workers meet with each patient at the bedside in the in-patient setting. After discharge, they meet with them again to assist them with additional resources and help them coordinate their care. Our Consulting RNs provide post-discharge follow-up calls to Renown Medical Group patients and ensure they have a primary care appointment, receive all necessary discharge referrals, understand discharge instructions and verify they have received all their medications.
- Chronic Care Management: RN Care Coordinators help patients and Community Health Workers partner together to help patients manage multiple chronic diseases through coordination of care, services and health education.
- General Care Management: Social Workers and Community Health Workers partner to assist patients with a variety of socially complex needs.
Among the many programs this team delivers, one major program of note is the Renown Prescription Food Pantry, which provides nutritious food to those experiencing poverty in our community and to patients who are facing food insecurity, which can be a detriment to their care journey. In partnership with the Food Bank of Northern Nevada and Urban Roots, CCM paves the way for easy access to food (and even pet food) in a one-stop shop environment. According to Shawnna Alto, Manager of Community Care Management, the impact of this program is remarkable.
“In 2022, our food pantry, which is staffed by our team of dedicated Community Health Workers, served 853 households and 2,111 individuals,” said Shawnna Alto. “Our pantry is open to the public weekly and provides those in our community who are in need with access to nutritious food.”
One of the major keys to leaving a lasting legacy on each patient’s care journey is education, equipping them with the knowledge, skills and resources needed to build their confidence in managing their health effectively. From chronic disease education for conditions like diabetes and heart failure to comprehensive support for food insecurity, this team empowers patients to make informed decisions, take control of their health and actively participate in their own care.
“Education is a huge part of what we do, as well as helping people access resources,” said Barb Mader-Scherrer. “We are out in the community in Reno, Sparks, Carson City and Fernley in the clinics and in patients’ homes. That face-to-face interaction really makes a difference in their long-term success.”
Even among pandemic resource challenges and any other obstacles that come their way, the CCM team leads with compassion to promote long-term wellness and self-care for every patient, regardless of their life circumstance.
“Our biggest challenge is having enough resources; we need resources for our patients who live alone, senior caregivers, injured veterans, patients with terminal illnesses and more,” said Irina Osmolovska. “Despite this, we are always ready to go above and beyond to advocate for our patients.”
“CCM is the new wave in healthcare,” added Christina Bankert. “We make a difference in the lives of people and keep their quality of life up and healthcare costs down.”
A Growing Team Among a Growing Population
With the rising cost of living in Washoe County and beyond, the need for the critical resources the CCM team provides and refers to continues to grow, and as such, the need for committed RN care coordinators, community health workers, social workers and consulting nurses to administer these services also grows. As their team expands, Renown’s CCM department is still actively hiring to continue to meet these needs and heighten their impact on our community.
Their recruitment efforts have not gone unnoticed – last year alone, the team nearly doubled in size.
“Our team has grown and developed significantly over the past year,” said Shawnna Alto. “Collectively, we carry an average patient caseload of over 900 patients on a rolling basis, and our personal care management program has seen cost savings of nearly $4 million. We are helping keep patients healthy and out of the hospital, and this means their quality of life is increased while improving utilization for the organization.”
“Washoe County in general is getting expensive, so when you have a fixed income or a family of five kids, how do you survive?” added Barb Mader-Scherrer. “We care so much in helping this growing population with accessing critical resources and navigating complex medical systems.”
This team shares something incredibly special together – a shared passion for helping those who may be facing adversity. And it shows in their teamwork and the way they are inspired to reach new heights every day.
“The team is very proud of being a collaborative group that supports one another,” said Shawnna Alto. “One of the consistent statements I hear as a leader among our team is that they feel it is a great culture and they truly enjoy their coworkers.”
“I am thankful for my Renown family and the amazing people I work with, both staff and patients,” added Steve Arm. “The culture and the teams I work with inspire me to do better and be better. I look forward to coming to work every day and being the best part of our patient’s day. I am proud to be a Renown Community Health Worker.”
CCM’s admiration for the work of our health system also drives their motivation to continue Fighting the Good Fight on behalf of all their patients.
“Renown has a visible presence in the community, and to me, that shows an effort to connect with the community we serve,” said Vanessa Alford. “I believe that while change can be difficult, it can create positive outcomes throughout the healthcare system. I see the administration making an effort to improve employee satisfaction and creating ways for patients to be more involved in their health care. In addition, the position that I hold as an RN is unique, and it allows me to have a successful work-life balance for my large family."
In the hearts of their patients and the community, Renown’s CCM department stands out as a beam of hope, compassion and unwavering dedication to improving the lives and nurturing the well-being of everyone they serve – resulting in an impact that lasts forever.
“We are all here to make a genuine difference in the lives that we touch – teamwork, communication and follow-through,” closes Sherrie Skaggs.