Health Care Providers Team Up with Chronic Care Coordination; Program Aims to Keep People Healthy at Home

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ROCK SPRINGS — A new way of caring for some of our most vulnerable residents is now under way in Sweetwater County, emphasizing a community approach to care that keeps people healthy and at home.

Kevin Franke, a quality improvement specialist with Mountain-Pacific Quality Health, said his group has been working the last six years on ways to reduce 30-day hospital readmissions.

Part of what Mountain-Pacific does is under the direction of the Centers for Medicare & Medicaid Services. Mountain-Pacific findings show 76 percent of all read missions with Medicare patients can be avoided through conversation, participation and everyone working toward the same goal, he told about 75 people during a recent community luncheon.

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Through a coordinated effort, a new Chronic Care Coordination Program has been launched. Franke said it’s a pilot program, and the first of its kind in Wyoming. There are stand-alone programs in Wyoming, but Memorial Hospital of Sweetwater County in Rock Springs and Castle Rock Medical Center in Green River are the first communities in the state to come together to work on this type of program.

“You will be combining Rock Springs and Green River in the care of these patients,” he said.

“We are so excited about this program and all that it offers,” said Sweetwater Memorial CEO Irene Richardson. “Working collaboratively is one of our core values as a hospital. The combined efforts of everyone involved is truly the definition of community. In the end, our patients reap the benefits.”

“I can’t say enough about how important it is for us to work together,” said Castle Rock CEO Bailie Dockter. “We will be reaching out to patients for more personal care.”

The program includes two care coordinators: Sweetwater Memorial’s Kati Moczulski and Castle Rock’s Rhiannon Sturlaugson, both registered nurses with bachelor of science degrees in nursing.

The program targets people who have two or more chronic conditions. To participate, a patient must have Medicare and a Sweetwater Memorial or Castle Rock primary care physician referral.

The program is a component of the patient-centered medical home concept, Moczulski said. It is in place to help people age in place in their home and exhibit more independence with chronic conditions they may be dealing with.

For example, someone with long-term heart problems, lung conditions or diabetes may find it hard to manage their own care, Moczulski said. They may have questions and don’t know where to go. They may have goals they don’t know how to achieve.

Why is it needed?

America is getting older, with an increasing population of people 65 and older, said Faith Jones, a care coordination director with Tennessee-based HealthTechS3. Consider this:

  • By 2030, America is projected to have 71.5 million people over the age of 65 – on Medicare.
  • One in five Americans will be older than 65 by 2050.
  • 87 percent of adults 65 and older want to stay in their current home and community as they age, she said.

“Wyoming, by 2025, will be No. 2 in the United States for oldest percentage of population,” Jones said.

The Chronic Care Coordination Program is designed to help guide people through the health care maze.

It has a triple aim:

  • Better health for the population; in this case, the Medicare population.
  • Better care for individuals.
  • Lower cost through improvement of care coordination.

It takes a village

The program’s approach is “we’re all in this together,” said Brad Putnam of Montana-based CrossTX. The company provides a clinical workflow designed around the best practices for care plans and chronic condition management involving the entire community. It can track the time staff spends coordinating care for patients and export chronic condition reimbursement reports to generate extra revenue through Medicare reimbursements.

Under the CrossTX program, other community members appointed by the patient can be invited into their care. It works similar to a social media platform, Moczulski said.

The program gathers information for patients that can help them with their health care needs. It can include a wide variety of resources, including neighbors, handymen, community health workers, visiting nurses, aging services such as senior centers, home-delivered meals, church groups, transportation, recreation centers and community care coordinators.

Putnam shared an example of how the program can help someone: An elderly woman had been to the hospital several times for injuries related to falls. A care coordinator checked on the woman and found that the patient didn’t have a railing on her front steps. A few calls were made throughout the community, a handyman was hired and a railing was installed at a total cost of about $65. The patient no longer suffered from falls and her health improved.

“It takes a village to raise a child,” Moczulski said. “It also takes a village to stay in our own homes as we age.”

For more information: Talk to your Sweetwater Memorial or Castle Rock primary care physician.