Care Coordination Helps Patients Overcome Social Determinants of Health

Imagine a stranger comes into your place of work for services and as you get to know her, you find out she is living on the street in 100-degree weather. What would you do? How would you help?

Arizona Care Network’s Care Coordination team was formed to help primary care providers address issues that aren’t exactly medical care, but certainly impact a person’s health.

Social determinants of health are the conditions in which people are born, grow, live, work and age that influence inequalities in access to healthcare and overall well-being.
World Health Organization, 2019

Over the summer, one of ACN’s health coaches, Jonas Hill, assisted a doctor with resolving the situation above.

“Care Coordination is a dedicated team of professionals who are always willing to provide excellent customer service to our patients in hopes of healthy and safe living,” Hill said.

Health coaches are part of the Care Coordination team to assist primary care providers by working to:

• Resolve social determinants of health
• Identify gaps in care
• Reduce/remove treatment barriers
• Assist patients with scheduling, transportation, and finding community resources
• Provide referrals to needed care specialists
• Support patients living with chronic health conditions

Identifying the Problem

• Hill was informed a patient was living on the street in the Arizona heat
• The patient needed shelter and access to prescribed medications
• She did not have transportation to a shelter

The Solution: Coordinating Necessary Care

• Hill contacted multiple shelters and eventually found one that agreed to provide the patient with over-the-phone intake and housing
• After multiple transfers from agent to agent trying to coordinate transportation for this patient, Hill arranged volunteer transportation to get the patient to the shelter the following day
• ACN Registered Nurse Michael Richards attended the intake meeting with the patient to ensure she was accepted into the shelter and had access to get her medications. He helped her answer questions shelter staff had regarding the patient’s health

The Outcome

• Patient was transported to a safe dwelling to get needed resources
• She now has access to necessary medications
• Shelter staff were well-informed on the patient’s healthcare needs to support her ongoing care

A Team of Healthcare Professionals in Your Corner

Care Coordination is available to all patients whose Primary Care Provider is part of Arizona Care Network. Our team works with your doctor to give you the extra support that makes it easier for you to get healthier and stay healthier.

There is no charge to the patient for care coordination services. For more information or to see if you are eligible, contact the ACN concierge line at 602.406.7226.