King County Care Partners: A New Approach to Care Management for High Risk Clients

People with multiple and complex health problems use more healthcare services than average: they take more medications, visit the doctor more frequently, and have higher rates of emergency room and specialty care visits.
 
A new chronic care management program—King County Care Partners (KCCP)— puts the patient instead of health care services at the center of the health equation. 

Care Manager Jeanette Choate. Says KCCP client Delores, "Jeanette helped me with so many things, including finding a doctor who understands me and who is concerned about my health. Even though I'm not in the program anymore, I still use the things I learned from Jeanette every day. I am so grateful to have had the chance to be in this program."  ________________

Delores, a KCCP graduate, felt her doctor was dismissive of her complaints and health issues.  A long history of domestic violence and substance abuse left her with neither the confidence to voice her concerns, nor the ability to seek care elsewhere.  With the help of her care manager, Jeanette Choate, Delores eventually found a clinic where she feels they listen to her and take her concerns seriously. Delores reports, "Since graduation, I am eating right, and have lost 35 pounds since August.  I also made a big step by adopting a cat. Having a pet makes me feel less alone, but it also helps me focus on something other than my own problems.  Having something to care for makes me feel good."

KCCP is a collaboration between health care practitioners and community service providers with a goal of improving health outcomes for high risk patients—people whose health concerns include multiple chronic diseases, mental health issues and a history of substance abuse. A team-based approach to care management helps patients develop self-management skills and encourages them to take personal responsibility for their health care. 

Once patients agree to participate in KCCP, they work with a Registered Nurse (RN) care manager, who begins by assessing the patient for a comprehensive set of concerns and abilities, including pain, depression, 

Sue Carstens is the newest member of the RN Care Manager Team with King County Care Partners. ____________________

functional status, alcohol and substance abuse, health literacy and self-management skills. The assessment is the first step in disentangling the complex array of issues impacting the patient's health—issues which are often overlooked by the patient's health care providers.

Both the patient and the care manager have access to a team of health care professionals with clinical, psychiatric, chemical dependency, social work and pharmacological expertise. The team consults regularly in order to identify issues and offer strategies for responding to everything from drug reactions to mental health behaviors. The RN care manager assists the patient in coordinating care, often accompanying the patient to medical appointments. Their presence is a combination of fact finding and advocacy on behalf of the patient, with the goal of teaching the patient both of these skills.

Adelle suffers from lung disease, and had been a frequent visitor to the emergency room because of difficulty breathing. With the assistance of her RN care manager, Adelle was finally prescribed an inhaler. This low-cost device has kept her out of the emergency room, but the need was not identified until the RN care manager and the care team helped Adelle troubleshoot the problem and advocate for this solution with her doctor.

Working with the care manager, patients identify steps they can take to manage their condition and agree to work towards completion of specific goals during the twelve month program. The RN care manager may help the patient break down difficult goals into achievable steps. For Adelle, "review information on smoking cessation programs" was a more attainable goal to reach than "quit smoking." 

Tia Halberg describes her RN care manager role as "teaching clients to access the tools they need to help themselves." Whether it is a relaxation technique or a medication organizer, the clients learn how to use the tool to promote their own well being. ___________________

This skill—the ability to break down goals into a series of steps—is one of several tools the RN care managers teach patients to use. By the time they graduate from the program, KCCP patients have acquired a toolbox of self-management skills, from relaxation and meditation techniques to cope with stress and anxiety to understanding how to navigate the health care system—all useful long after their participation in the program.

Tia Halberg, an RN care manager with ADS, introduces these tools to her patients through a process of motivational interviewing. She describes this as "meeting the client where they are at, emotionally and physically." Patients may not be responsive to learning how changes in their diet will help manage their condition, but they may be willing to do a few deep breathing exercises. Tia takes it one step at a time, letting patients determine which tools they are ready to acquire. 

Adelle, who recently graduated from the program, has not yet quit smoking, but she has cut down on how much she smokes and hopes to set a date for quitting soon. She regularly practices breathing techniques, which helps reduce her stress and her shortness of breath, and she participates in an exercise and art program for both her mental and physical well being. She is an active participant in her own health care.

This program is available to patients who are on the Medicaid fee-for-service program and who are identified by the Washington State Department of Social and Health Services (DSHS) as "high ulitizers" of health care services. The partners include Aging & Disability Services (ADS); Harborview Medical Center; Senior Services; HealthPoint, Neighborcare Health, and Sea Mar Community Health Centers; Washington State Health & Recovery Services Administration; and almost 300 patients in King County who are active participants in their care management teams.

For more information on King County Care Partners, contact Rosemary Cunningham at 206-684-0655.