A community approach to keep people healthy and in their homes

It sounds simple, but for an older person with several ongoing health issues, being able to walk their dog every day can be a milestone in keeping their independence.

Mary Workman brought her brother Bill Borthwick to Wyoming from Virginia five years ago to be closer to family. Bill’s disability and health issues were becoming more and more difficult for Mary to manage from her home at Devils Tower, and CCMG Internal Medicine Dr. Nahida Khan suggested Chronic Care Management as a way to help him maintain his independence.

A new program through Campbell County Medical Group, Chronic Care Management coordinates care under a single healthcare provider and involves a whole team of resources to encourage and provide needed assistance for Medicare patients with two or more chronic health conditions. The patient’s family and friends, and local organizations like the Campbell County Senior Center and Campbell County Public Health all work together with the healthcare provider to help them reach their goals.

The additional resources provided through the program have changed many aspects of Bill’s life for the better. A course of physical therapy helped Bill with strength and balance. Concerns about nutrition led to home meal delivery and healthier foods. A visiting nurse manages his medications to make sure he doesn’t run out and coordinates refills when needed.

“Our goal is to keep that patient out of the hospital and the Emergency department,” says Care Coordinator Lise Necklason, RN. “I help them set the goals they want to reach and also connect them to resources they sometimes didn’t even know were out there.”

After a patient enrolls in the program, Lise talks to them every month to see how they are doing and listens carefully for cues that may indicate changes in their health or other needs they may have. She can then communicate with their provider to schedule appointments, change medications or determine if other services are needed. She is also available to answer questions that may come up in between appointments.

“We’ve been able to intervene sooner and prevent some more serious complications that could have happened,” says Lise.

“Bill wanted to stay in his home,” said Mary. “He’s not a naturally social person, but now he’s looking forward to visits from his various caregivers. It’s helped him with social interactions. For me, it’s so reassuring to know that he can have the independence he wants, get good care and be safe.”

About 35 patients are currently in the program, with plans to start enrolling more as interest grows. Patients must have a primary care provider that practices at one of the Campbell County Medical Group clinics in Gillette, Wyoming, be enrolled in Medicare and meet the program’s health criteria.

For more information about Chronic Care Management, call Lise Necklason at 307.688.3670 or visit www.cchwyo.org/ccm.

Photo: Mary Workman and her brother Bill Borthwick are taking advantage of the Chronic Care Management program, connecting patients with the resources Bill needs to stay independent and reach his personal goals.