Helping Case Managers Coordinate the Right Care for Patients

Date: March 9th, 2016Category: CORHIO e-NewsletterTopics: Care Coordination, Population Health, Transitions of Care

 

Longmont Community Health Network uses CORHIO’s PatientCare 360® to coordinate care for patients over-utilizing the emergency department.

Longmont Community Health Network is a small but determined organization that focuses on helping patients who have “fallen through the cracks” in the healthcare system. Christa Peacock is the sole case manager for the group and helps patients get the right care, as many rely on the emergency department at Longmont United Hospital for their needs.

The group will help patients with whatever it takes to get them on the right track – whether it be assistance with food, housing, exercise, hearing aids, medications, referrals to primary care physicians, behavioral health and even help with insurance. “We connect with patients after their hospital visit and follow up to make sure they’re medically supported in-home,” says Peacock.

Connecting to Community Health Record

Peacock relies on CORHIO’s PatientCare 360® online portal to look up each patient on her list, seeing what she can find out. “I go in and find out how many times they’ve been in the hospital, how many times they’ve been in the ED,” she says. “For one client, we found out she had an ED pattern and was requesting medication each time she went in. I was able to bring in mental health support and help her manage her symptoms the right way.”

Because Longmont Community Health Network works as a central point for their patients – getting them help from appropriate resources like a free clinic, a senior center or a behavioral health provider – any information they can find on the patient might be helpful. “I’ve even found records from ED visits up in Summit county,” says Peacock. “One of my clients was 19 years old and I found some information through Children’s Hospital that he already had a social service person assigned to him. We put our heads together to figure out how to best support this kid.”

Saving Time on Phone Calls

Before she had access to the CORHIO database, Peacock had to make lots of phone calls and rely on the patient’s recollection of their medical histories, which was challenging. “Now I can access the CORHIO face sheets, labs, H&P and discharge summaries and make that part of my client’s record with us. I’ve had to wait up to 7 days for records before, so this is really helpful.”