Helping Patients with Complex Medical Needs
Our Intensive Outpatient Case Management Program
Q&A with Catherine Cappelletti, BS, RN, PHN, Nurse Care Coordinator
What is the Intensive Outpatient Case Management Program?
This is a RN-led program that coordinates care for patients with multiple chronic illnesses and/or complicating social factors such as homelessness. We help by coaching them so they can better manage their chronic conditions and we also connect them with the services they need. The Program was developed by Partnership HealthPlan of California (Medi-Cal’s insurance program for Marin County), which saw a need to provide better care for these patients and improve their health outcomes.
What kind of patients are in the program?
To qualify for the program, patients must be enrolled in Partnership HealthPlan and have at least two chronic conditions – examples are asthma, diabetes, congestive heart failure, brain injuries, and behavioral health diagnoses. Plus, they must have a recent history of multiple emergency room visits or hospital admissions. We currently have about 40 patients in the program.
What kind of help do you give to patients?
I help patients develop their personal health goals, provide support in improving their self-management skills, coordinate with the Clinic care teams to reinforce patient goals, and bridge any potential gaps between outside specialists. All of this adds a level of care that can make a big difference.
The patients and I have frequent check-ins – either in person or via telephone. These check-ins also allow patients time to discuss questions and concerns prior to their next appointment. Importantly, since I work closely with them, I am able to identify seemingly subtle factors that may be affecting their overall lives and health maintenance. If additional services are needed, I assist with referrals, coordination and follow up.
Jaime Faurot (age 46 and a native of Malaysia), has been a Clinic patient since 2012. She suffers from a host of problems – extreme chronic pain due to spinal stenosis, hypertension, fibromyalgia, gastric issues, and stress. Life can be a struggle, given her limited functioning and the difficulty finding the right care. As she says, “tying it all together is hard.”
Working together to sustain care
Earlier this year, Jaime became part of the Intensive Outpatient Case Management Program. “Working with Catherine has made it more manageable,” she reports, “and I depend a lot on the Clinic. She is always finding ways to help me – even things that may seem simple, like getting me a biofeedback machine that I couldn’t otherwise afford, finding transportation to my medical appointments, or making sure that specialists have my medical records.”
In addition to frequent visits and calls with Catherine, Jaime sees her primary care physician at the Novato Clinic twice a month. She receives acupuncture, chiropractic care, trigger point and steroid injections, as well as physical therapy. She also utilizes the Clinic’s weekly pain and stress management classes. Given her medical complexity, she faces ongoing challenges, such as communications with insurance companies and timely referrals to specialists. “It’s a long journey and not always easy,” concludes Jaime, “but we are working together to sustain my care.”