Patient-Centered Medical Home Welcomes New Care Manager

by Lindsay Cortina, Director of Organizational Initiatives | Dec 30, 2016
Christine Cruse
We know the healthcare system is complex and it can be difficult to navigate your way to good health. We also understand that healthcare costs are higher than ever and that patients nationwide are experiencing increasing out-of-pocket costs for care. In an effort to ensure our delivery of care is aligned with patient needs and is structured in the most cost effective manner, we have spent the greater part of this year implementing a new model in Primary Care – the Patient-Centered Medical Home. Although the Patient-Centered Medical Home term may be new to you, this is a model of primary care we have always delivered at Sansum Clinic, with a focus on comprehensive, team-based, coordinated care, and an emphasis on quality and safety.

At Sansum Clinic, our Patient-Centered Medical Home is not a place, it's a partnership among practitioners, patients and families, and other members of the healthcare team to ensure that you have the education and support you need to make informed decisions and participate in your own healthcare. Your primary care provider (PCP) is the leader of your care team, which often includes Physician Assistants/Nurse Practitioners, Registered Nurses and Licensed Vocational Nurses, Medical Assistants, and Medical Service Coordinators. This core Care Team works closely with Sansum Clinic specialty departments and other support services such as a Prescription Navigator, Health Educators, and now – a Care Manager, to ensure you receive excellent care in the right place, at the right time, and in the manner that best suits your needs.

Our Care Manager, Christine Cruse, is a crucial member of the Care Team who helps patients overcome potential barriers to care. She may arrange social services, transportation services, medication reminders – whatever it is that might get in the way of you receiving high quality care. Christine assists patients in managing their health conditions, prioritizing their healthcare needs, and navigating an increasingly complex healthcare system. This new, vital role, enables the physician to spend less time coordinating the care and more time giving patients personalized medical attention.

As Care Manager, Christine works closely with patients to track progress toward achieving health goals while managing their chronic conditions. Patients and their family members act as "partners in care" by identifying their personal goals, engaging in education, and participating in strategies to facilitate compliance. She provides education and referral to Clinic and community resources as appropriate, including Sansum Clinic Health Education classes. During a Care Management visit/telephone call, Christine gives special attention to care planning and self-care support, including creating individual self-care plans that incorporate patient preferences, lifestyle goals and treatment goals; address potential barriers to meeting goals and strategies; and include current problems, medications, and allergies. Each patient receives a copy of this self-care plan, which can be used as a "roadmap" to improving health. This plan is revisited in future Care Management appointments, and progress is documented and shared with the patient's PCP.

Our Care Management program is supported by our robust, integrated electronic health record, the Wave. With a patient's comprehensive health information at her fingertips, our Care Manager is well-equipped to care for the whole person, not just their immediate health concerns. The Wave also allows Christine to communicate across and between the entire healthcare team.

Over time, this program will help ensure that patients living with complex conditions, and/or disabilities or in active courses of treatment avoid disruptions in their care. It will minimize the potential for duplication of services, eliminate gaps in services provided, and ensure that care is provided to individuals as seamlessly as possible. These outcomes will result in enhanced quality of care and patient satisfaction, while also potentially reducing the cost of care by decreasing duplications in care and hospitalization.

Christine Cruse, MSW, Care Manager received her Master's of Social Work from CSU Long Beach and has more than 20 years experience as a healthcare social worker. Prior to joining Sansum Clinic, Ms. Cruse worked as a Medical Social Worker at the Santa Barbara Artificial Kidney Center where she helped guide chronically ill patients through the disease process and helped them set goals to maintain or improve their physical, emotional and social well-being.