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Making sure no one falls through the cracks

"The community really wrapped around her. It’s so simple really." ~ Richard Lewis, social worker with the AllCare Health Plan.
AllCare Health Plan building

AllCare Health Plan, a coordinated care organization serving people in Curry, Josephine, Jackson and parts of Douglas counties

Richard Lewis is a social worker with the AllCare Health Plan, a coordinated care organization. His job is to make sure no one falls through the cracks.

AllCare serves Oregon Health Plan patients in Curry, Josephine, Jackson and parts of Douglas counties. Lewis is part of a team that meets to figure out why some patients come to hospital emergency departments so frequently.

"We talk about what's going on with the patient. What does the patient need? Why are they going to the ED so often?" said Lewis, a licensed clinical social worker. Then a team member works directly with the patient to figure out these answers.

With a coordinated, patient-centered approach, the team helps people get the care they need through primary care providers or other community resources. This approach can result in better overall health for patients, as well as helping to prevent expensive emergency medical care. Patient-centered care is a keystone of the coordinated care model.

Lewis gave an example of a woman who had been in the emergency department four times in one month. She was having housing problems, law enforcement issues, was often homeless, had uncontrolled diabetes, high blood pressure, pain and severe mental health issues.

Due to the complex issues involved, the team got to work. They held a meeting to decide how best to help her. Then, Lewis began talking with her to figure out what the barriers she was facing. He listened to her.

"She knew she needed to try medication and therapy, but going to the doctor made her irritable. She told me she got that way because she had to stand waiting for the front desk to register her. Her knee hurt when she stood too long and then she got irritable with the front desk staff. We worked out that she could sit and use her wheelchair," he said.

Lewis connected the woman with a primary care provider, MountainView Family Practice, a state certified patient-centered primary care home in Grants Pass. Then he found her a supportive residence in housing that also offers some services to help her live a more stable and productive life. So far, she is staying out of the emergency room, her health conditions are improving and she is gaining stability in her life.

"The community really wrapped around her," said Lewis. "It's so simple really."