The WVCH interdisciplinary team includes (from left) Nicolette Venegas, non-traditional health worker; Kim Schmaltz, nurse case manager; and Veronica Sheffield, nurse case manager director.
June 3, 2013 (Salem) – When Willamette Valley Community Health looked for ways to improve the care they provide to Oregon Health Plan members, the coordinated care organization focused on a special population: 15 to 20 members who live with chronic illnesses and who are frequent visitors to the emergency department.
"The emergency department is great if you're having chest pains, or you’ve been in an accident – some health crisis," says Veronica Sheffield, the CCO's medical management director. "But for chronic care such as for diabetes, the patient will most often be better served in a primary care setting."
In one striking case, a member who had made 70 trips to the emergency department between January and November of last year has been back just once in the last six months.
To better serve these members, the CCO added nontraditional health workers like peer mentors and community health workers to an interdisciplinary team that includes a psychiatrist, a nurse case manager, a primary care provider, and – most importantly, Sheffield says – the patients themselves.
Nontraditional health workers may accompany members to medical appointments and advocate on their behalf as they navigate the health care system. They help members shop for healthy foods, teach them how to prepare meals, help them find mental health care, housing – whatever patients need to stabilize their lives and improve their health.
Over just the first few months of the program, Willamette Valley Community Health saw a 50 to 60 percent reduction in emergency department use among participants. In one striking case, a member who had made 70 trips to the emergency department between January and November of last year has been back just once in the last six months.
Successes like these have prompted the CCO to expand the program and reach more members with the right care, at the right time, and in the right place.
"We try to get their needs met before they need an emergency department visit. We work to ensure they have the right providers and access to the right services for their unique needs," Sheffield said.