Seeing the Background ‘Patient Story’ Empowers Family Care Coordinator
Being able to view a background ‘Patient Story’ - comprised of clinical data, psycho-social data and lifestyle data - has enabled Family Care Coordinators to contribute to improving the care plan and the health outcomes of their patients at the Regional Center for Border Health in the small rural community of Somerton, Arizona, only a few miles from the U.S./Mexico border.
|Family Care Coordinators at the Regional Center for Border Health Clinic in Somerton, AZ, are using a new, innovative data collection tool, called the Lifetime Health Diary, to paint their patients’ complete health stories.|
The Regional Center for Border Health, Inc. (RCFBH) is committed to providing quality health care to those living in Western Arizona and the Arizona-Mexico border area. Always seeking innovative opportunities to enhance the skills and tools for their Community Health Workers (“Family Care Coordinators” at the Center), who work directly with patients, the RCFBH teamed up with a company called Lifetime Health Diary, LLC to utilize a new approach in helping manage a patient’s health condition.
“Delivering high quality primary care is imperative for improving patient outcomes, as well as reducing the cost of healthcare and increasing efficiency in the delivery of care. The Lifetime Health Diary™ provides the tool for our Family Care Coordinators and medical providers to better manage patient care that results in better health outcomes and patient engagement,” said Amanda Aguirre, President & CEO of the RCFBH.
The Lifetime Health Diary™ (LHD) is a web-based application that brings together key clinical, psycho-social, and lifestyle data for a health provider to see a more complete Patient Story than when viewing only clinical data. The following case study reflects the significant value of the information and how the patient data can be used.
A Hispanic, Spanish-only speaking male in his mid-70s, is a RCFBH diabetic patient and not computer literate. Since 2000, the patient has been on an anti-anxiety drug, Clonazepam, but due to changes in his Primary Care Physician, the original reason for prescribing the drug was institutionally forgotten.
When a Family Care Coordinator (FCC) used the LHD application to paint the background Patient Story, she noticed that the patient had reported significant distress when his wife died in 2000; hence the Clonazepam prescription. The FCC also noticed, however, that stress was no longer impacting this patient’s life in recent years. As a result, she encouraged the patient to have a dialogue with his provider about this medication and she explained to the physician that the LHD showed that the patient was no longer experiencing stress/anxiety. The end result was that the physician stopped giving the drug to the patient.
|Using the Lifetime Health Dairy and other health education materials, a Family Care Coordinator found out that the reasons for this man’s drop in physical activity and number of daily meals were directly related to his moving in 2010 and losing some of his housing subsidy.|
“The Diary provided a platform on which to record psychosocial data, like anxiety, that the FCC was already collecting from the patient through her everyday work. Furthermore, she was able to identify patterns and provide information to help the medical provider with a more comprehensive assessment of the patient’s psychosocial and health status,” said Alex Valenzuela, Director of Health Education, RCFBH.
In addition, the FCC used the tool to discover that the patient moved in 2010. Simultaneously, the LHD also showed a clear change in the patient’s pattern of exercise and nutrition. He reduced his walking every day to only occasionally and his meals fell from 4-5 per day to only 2 a day. As a result, the patient’s LDL, HDL and HbA1c stats all deteriorated. Until seeing the clear information in the patient’s background story, nobody had noticed any correlation to the life event of moving back in 2010.
After talking with the patient, the FCC also discovered that finances were the issue. In 2010 the patient’s housing subsidy diminished and led him to cut back on meals to get by. The Diary’s data display of background information led the FCC and the rest of the care team to get the patient two extra hot meals a day via Meals on Wheels. Since then, the patient’s condition has improved with less hypo-glycemic episodes.
Through the use of the Lifetime Health Diary, the Family Care Coordinator was empowered to connect the dots between clinical data, psycho-social data, and lifestyle data to significantly improve and rationalize this patient’s care regime. The patient continues to be healthier as a result of the application of this innovative care coordination tool.
About the Author
Joyce Hospodar, MPA, MBA, has worked as the senior program coordinator of the Medicare Rural Hospital Flexibility (Flex) Program since 2001. She is responsible for providing technical assistance in gathering, organizing and presenting required data for rural Arizona hospitals seeking federal designation as a Medicare Critical Access Hospital (CAH) under the Flex program. firstname.lastname@example.org