Home health visits keep Grants Pass man out of the hospital
La Clinica del Valle Central Point Clinic
Jackson County, OR
Before Stephen Calhoun connected with a primary care team at La Clinica in Jackson County, his health care services were driven by emergencies. He would wait until his uncontrolled blood pressure spiked or chest pain flared or he was out of breath. Then he'd land in the hospital.
"I was in and out of the hospital — sometimes once a week," says Calhoun, a 59-year-old woodworker who lives in a trailer park near Grants Pass. But in the year since La Clinica helped teach him how to take better care of his health, he has not visited a hospital once.
Calhoun has high blood pressure, coronary artery disease and diabetes. He is covered by the Oregon Health Plan.
State officials have recognized La Clinica as a Tier 3 Primary Care Home — the highest level — because of its commitment to patient-centered coordinated care. Primary care homes are key to health transformation in Oregon, because they target chronic illnesses in time to prevent costly medical emergencies.
A pilot program through La Clinica used home visits to help Calhoun take control of his diabetes.
"If you really want to help people with chronic conditions," you have to look beyond the occasional visit in the doctor's office, says Karen Gonzalez, clinical nurse supervisor at La Clinica. She visited Calhoun repeatedly last year to help him come up with a plan for managing diabetes.
They counted calories, traded recipes, inventoried his refrigerator and mapped realistic strategies. How to prepare meals that are simple, tasty and healthful. How to interpret nutrition labels, and to use food stamps to stretch his grocery budget.
A community health worker visits Calhoun at least monthly to check on his progress. "We go over everything I'm doing," he says. "It has really helped."
Calhoun wears a nitroglycerin patch to relieve chest pain and takes pills for high blood pressure and diabetes. But weight loss and improved diet have helped him avoid insulin.
"When I go shopping nowadays, I'm buying things I didn't used to buy: fresh veggies, low-salt items, 2 percent milk," he says. His weight has dropped to 185 lbs., from over 200. He gave up the salt shaker. His drink of choice is now plain water.
"I feel better," he says. "I don't have any problem with the government having to put out less money because I'm spending less time in the hospital.
"It's a win-win."