Coordinated Care Alleviates Stress by Connecting Patients to the Care They Need

Have you ever felt like no one cares about your health concerns? A new patient in one of ACN’s Comprehensive Care Clinics was calling the office daily and was very emotional about her healthcare. She had a long list of specialists she wanted to see for a variety of medical concerns and the office staff had no orders for those referrals on record. That’s when ACN’s Care Coordinator, Tiffany Wallace, RN, stepped in.

“No one calls the doctor’s office crying for no reason,” Wallace said. “I asked her primary care physician if he would refer her to Care Coordination so I could meet with the patient. At this point, she was so frustrated that she didn’t even want to come in for the appointment she was scheduled for.”

A Listening Ear

Wallace met with the patient the following day and listened to her. For four hours that afternoon, she worked through each of the patient’s healthcare concerns. Wallace documented the previous doctors she had seen and tracked down the referral orders the patient was requesting.

“This wasn’t a ‘difficult’ patient. She was a scared patient with multiple medical issues, who legitimately needed to see several different specialists on top of the psychiatrist appointment she was there for,” Wallace said, “Her concerns were valid, but she wasn’t being heard.”

Wallace asked the patient’s primary care provider if they could hold a care conference for the patient and he agreed, so they assembled the team of healthcare professionals needed to address each of the patient’s needs.

“Care coordination is especially important for patients like this one because sometimes the healthcare system can be very difficult to navigate. This causes patients a lot of frustration and sometimes they even give up on their healthcare,” Wallace said.

Through research, Wallace found the patient had suffered a prior stroke, which wasn’t in her new medical record. Wallace was able to share the patient’s comprehensive medical history at the care conference, and under the physician’s guidance, they created a treatment plan to address all her healthcare needs.

The primary care physician listened to the patient’s medical concerns, explained her diagnoses and his plan of care, and answered all her questions. After the care conference the primary care physician provided the referrals she had been requesting.

Care Coordination Did Not Stop There

The Care Coordination team continues to assist this patient with her healthcare concerns and needs. Maricela Becerra, a Navigator, now reaches out to the patient weekly to check on her progress. They have created a folder of her concerns, prioritized from highest to lowest and Becerra helps her make progress on her health goals each week.

“Maricela reaching out to her weekly has the potential to improve the patient’s overall care. She helps the patient manage multiple appointments, provides support in managing her medical conditions, addresses any of her care concerns between office visits, and helps the patient secure transportation when needed,” Wallace said.

Interested in learning more or seeing if you are eligible for Care Coordination? It’s a free benefit for Arizona Care Network members. Contact the ACN concierge at members@azcarenetwork.org.