Care Coordination is crucial as healthcare is shifting towards value based care, not only does it improve the patient's experience of care, it also can improve health outcomes and reduce costs. The value of care coordination has become even more significant during the Covid public health crisis. Read how the care coordination team at the Associates of Family Medicine(AFM) has adapted to accommodate the needs of the patients and care teams during the crisis. Their team has been an anchor of steadfastness, strength, support, and security for providers and staff during a time filled with stress, uncertainty, and insecurity.
Associates in Family Medicine, P.C. is a primary care practice that consists of nine full-service offices and more than 50 medical providers throughout Northern Colorado. The Social Work Care Coordination team, comprised of fourteen master’s level social workers, is integrated within the multi-disciplinary care teams at each office, as well as in the community. The Care Coordinators provide support in a variety of ways, including brief focused behavioral health interventions, addressing and resolving barriers to medical and mental health care, providing resource connections and referrals, identifying and supporting biopsychosocial needs in conjunction with medical needs, and more.
- “A reliable or principal support”
- a symbol of steadfastness, hope, security, and strength
The year 2020 has been compared to great, unprecedented, devastating storm. Associates in Family Medicine, like every individual, family, business, and community, was challenged to weather this storm in a way that mitigated damage and strengthened our organization while continuing to provide outstanding care to those we serve. The Care Coordination team has been an anchor for our organization throughout this storm.
In “normal times”, the Care Coordination team is a steadfast source of encouragement and creative innovation. We are a “reliable and principal support” for our patients, colleagues, organization, and community. Our distinctive skills and training in the areas of mental health, case management, resources, health behavior change, and the whole-person approach are invaluable to our patients and providers. As one provider recently said, “Having a Care Coordinator in the office changes the way we provide inclusive and holistic care to our patients. We need your skill set in our offices.”
We diligently support and advocate for all of our patients, especially during patients’ most vulnerable moments. We provide crisis intervention, immediate in-office care that patients would otherwise have to seek elsewhere, as well as encouragement and accountability to patients striving to make positive changes in their lives. We decrease barriers to healthcare and increase successful outcomes. We give voice to unspoken or overlooked needs, and we create space to care for the whole person by exploring the numerous complex biopsychosocial factors impacting patients’ health and wellbeing.
In “normal times”, we are attuned to staff struggles and provide emotional support and reassurance, especially when the days are hard. We also know the value of laughter and celebration, and frequently point out strengths. We uplift those around us, and find the gratitude and joy in even the most difficult of situations. We collaborate with our staff to optimize processes and continually improve patient care. We develop and help manage pursuits such as patient support and education programs, presentations for staff on a variety of topics, multi-disciplinary healthcare quality initiatives, improving all-agency care for LGBTQIA+ and other marginalized populations, community training for an improved suicidality response, and more.
In “normal times”, we listen deeply, validate earnestly, and “meet people where they’re at” in a world where most do not have – or make – the time. We are resourceful, flexible, dedicated, and genuine in our care.
As everything changed around us and our patients, we provided guidance to patients feeling lost in the confusion of navigating healthcare in 2020. We adjusted our focus to accommodate the pervasive rise in anxiety, depression, trauma, loneliness, and grief, supporting more and more patients through panic attacks and other acute manifestations of stress and anxiety, suicidal ideation, and complete overwhelm. Our caseloads grew and the acuity of patient needs increased; yet we continued to offer all the same services that we have historically provided.
The year of the storm, 2020, was not “normal times”, and the Care Coordination team responded to the myriad of new challenges faced by our patients, coworkers, and agency in dynamic and innovative ways. The needs of the patients we serve and the employees we support changed almost overnight and have continued to shift and change as the mass trauma experienced by our community continued to develop, deepen, and transform. We adjusted patient care and education curriculum to virtual formats, learned “on the fly” about quickly-changing community resources, and built upon existing relationships with community agencies to ensure our patients had access to services. As everything changed around us and our patients, we provided guidance to patients feeling lost in the confusion of navigating healthcare in 2020. We adjusted our focus to accommodate the pervasive rise in anxiety, depression, trauma, loneliness, and grief, supporting more and more patients through panic attacks and other acute manifestations of stress and anxiety, suicidal ideation, and complete overwhelm. Our caseloads grew and the acuity of patient needs increased; yet we continued to offer all the same services that we have historically provided. Our patients have expressed deep gratitude for feeling heard, validated, and supported during extraordinary societal and personal challenges. Patients have called us their “safe haven,” and have said that it is “amazing” that this practice cares enough to have us in each office, as well as in facility settings. We have been an anchor of connection and care for our patients, especially those experiencing isolation and suffering.
We have been an anchor of steadfastness, strength, support, and security for providers and staff during a time filled with stress, uncertainty, and insecurity. In addition to continuing to care for patients, the Care Coordination team paid close attention to the needs of our fellow staff. We supported self-care efforts, provided staff with anxiety and stress management education both formally and informally, and successfully advocated for doubling EAP counseling sessions offered to employees. We supported our coworkers by openly acknowledging and normalizing the communal experience of grief and trauma that staff experienced, as well as the associated compassion fatigue. We identified and shared resources for staff, and worked with a partner agency in the community to provide free counseling sessions for employees. During this year, more than ever, providers and staff have shared that they could not provide the quality care Associates in Family Medicine is so proud of without the Care Coordination team.
Furthermore, during this challenging year, the Care Coordination team continued to impact important efforts for our organization as a whole. We expanded our ability to bill for direct services, providing increased revenue to help mitigate the decrease in outpatient visit volume. We provide leadership in each office in support of quality initiatives, which impact reimbursement. We have championed and led the organization’s new Health and Workplace Equity Committee. We have collaborated with administration and marketing to help craft and communicate messages to our community about what our company stands for and prioritizes during these contentious times. We have been a grounding and consistent factor as the agency has gone through unprecedented changes.
In the context of relationships, an anchor represents “a strong, deep, resistant and invincible bond”, and the Care Coordination team – as a group of individuals – embodies this ideal. We come from a broad variety of experiences, abilities, skills, and expertise. We utilize this diversity of knowledge as an invaluable collective strength when addressing challenges. We all cohesively acknowledge that we are better together and could not do this work alone. We build and maintain our team synergy through constant communication and cooperation, helping and supporting each other as workloads change and challenges present themselves, both professional and personal. We are intentional in our expressions of mutual respect and admiration, as evidenced by our encouraging, positive group communication. We also authentically like each other and have fun together, both at work and outside of work.
We supported our community through anxiety, loss, anger, and struggles, all while mitigating our own losses and navigating our own personal struggles. We were relentless in our efforts to remain connected – listening, encouraging, and reminding each other of the importance of maintaining our own health and wellness. We are simultaneously each other’s anchors and a collective anchor at Associates in Family Medicine.
We build and maintain our team synergy through constant communication and cooperation, helping and supporting each other as workloads change and challenges present themselves, both professional and personal. We are intentional in our expressions of mutual respect and admiration, as evidenced by our encouraging, positive group communication.
As we move into 2021, the Care Coordination team will continue to be an anchor in the storm. We will continue to be present, grounded, resilient, and creative for our patients, staff, organization, and each other. We will continue to be “a reliable support” and a symbol of steadfastness and hope, regardless of what lies ahead.
Written by Erin Sullivan-Ortiz, LCSW CCM, Associates Family Medicine, P.C.
The Social Work Care Coordination team won Associates in Family Medicine’s 2020 Team of Excellence Award with this essay.
The Social Work Care Coordination team at Associates in Family Medicine, P.C.
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