When Linda S. received a positive result on her Cologuard screening test, worry set in. The 75 year-old grandmother worried she might have cancer, and would need to coordinate traveling from her home in north Santa Barbara County for the required colonoscopy. Population Health Department RN Supervisor Mary Arimoto connected with Linda as part of her colorectal cancer screening reminder outreach. With time of the essence, Mary helped to coordinate Linda’s procedure with Sansum Clinic’s Gastroenterology Department. She ordered the colon prep medications Linda would need right away at a nearby pharmacy, and walked her through each step of the screening. “Mary didn’t miss a beat,” recalls Linda. “She told me she knew how distressing this can be. She was an angel that appeared for me just when I needed her.” Linda was relieved to learn the results of her colonoscopy were clear, and the gastroenterologist removed several polyps, reducing the chance of cancer occurring.
Mary and her colleagues in Sansum Clinic’s Population Health Department are focused on finding ways to provide 
patients with the best care in a fiscally responsible manner. The term population health refers to the study of all the factors which can influence a group’s well-being. It’s a way to determine the overall health of a specific part of the population, by examining the underlying barriers to care, and the preventive measures which can be drivers to good health. These care coordinators and registered nurse care managers help with preventive healthcare needs and coordination of care for all primary care patients, including those who are medically high-risk. They work diligently behind the scenes, yet contribute immensely to the quality improvement. "To coordinate care for thousands of patients, we spend a great deal of time doing outreach by phone, text, and MyChart,” explains Registered Nurse Jen McGahey, Primary Care Service Line Manager. "We work with our physicians to ensure that preventive care is addressed during their visits. This is the best time to educate them about screenings, and managing their chronic medical conditions". Monitoring high blood pressure was a specific target at the end of 2023. The team identified patients with elevated readings during their last medical visits and then followed up with those people to coordinate new readings either at home for, or in Clinic. If the results indicated hypertension, the nurses looked at whether medication was needed or if it had been refilled, or if these patients required a follow up visit to discuss how to get their blood pressure lower.
McGahey and her team pay special attention to Medicare and Medicare Advantage patients, and are beholden to the accountable care organizations (ACOs) which demand that these individuals receive high-quality care while also having their costs lowered. One critical role is smoothing patients’ transition home from hospital stays or visits to the emergency room. The nurses review the roadmap for recovery so patients understand discharge information, any needed tests or treatments, medications which may be stopped or started, the physician’s instructions for recuperation, and any referrals for specialists or services. “The goal is to enhance the patient experience, while coordinating all these needed appointments, and helping patients manage their chronic medical conditions, to keep them out of the hospital and as healthy as possible,” commented RN Care Manager Jillian Nordella.
Data collected by the ACOs shows efforts by transitional care management teams can make a big difference. Sansum’s ACO partner Aledade reports that on average, seven hospital discharge outreaches prevent 1 rehospitalization. Approximately 12 emergency room follow-up outreaches prevent 1 emergency room repeat visit. “We are seeing similar results here at Sansum Clinic. The Population Health team has reduced hospital readmissions due to successful transitions out of the hospital, and has made a tremendously positive impact in the lives of our patients because of their extensive outreach to bring people in for colonoscopies, mammograms and other types of required screenings,“ said Bryce Holderness, M.D. FACP, Director, Accountable Care Organization, Department Chair, Pesetas Internal Medicine Department.
Bryce Holderness, M.D. FACP, Director, Accountable Care Organization,
Department Chair, Pesetas Internal Medicine Department
The Population Health team examines data and trends within the Clinic’s electronic health record to identify care gaps, as well as the trends and differences, in groups of patients. They follow the digital trail to uncover missed or overdue appointments, and to connect patients to specialty care when it is required, for example when diabetic patients need visits with endocrinologists, ophthalmologists and optometrists to properly manage symptoms of their disease. Care Coordinators reach out to Blue Shield Medicare Advantage patients, and those with Medicare Part B primary coverage that are members of the ACO, to schedule their annual exams. The addition of advanced practice clinicians has helped to expand access. At Sansum’s 317 W. Pueblo Street location, highly-skilled nurse practitioners in the Preventive Care and Wellness Department partner with primary care doctors to provide these annual preventive care visits. The reminders from the Population Health team are greatly appreciated, according to McGahey. One patient messaged the team in MyChart “I want to thank you for your personal attention to my challenge. You did what you said and found an immediate appointment. I am very grateful for your assistance. Your title of “Care Provider” is quite accurate.”