It Takes a Community

Rebecca BrysonRebecca Bryson is a patient with extensive experience with the health care system. She has 10 different medical conditions and depends on the services of 13 health care providers. Managing her various conditions with so many different providers is challenging at best. A unique community-wide effort in Whatcom County, WA is making that challenge easier for Rebecca and many other patients.

The problems in the health care system in Whatcom County are similar to those found in communities throughout the country. For the nearly 100 million Americans who now have one or more chronic illnesses — a number estimated to grow to 134 million by the year 2020 — these systemic failures can have a devastating impact.

Responding to the needs of patients struggling to manage their diseases, especially those with multiple chronic conditions, a group of health care representatives in Whatcom County decided to work together to redesign their care delivery. Participants include the community hospital, a specialty group, clinics, and a physician practice. This collaborative effort was selected to participate in The Robert Wood Johnson Foundationģ initiative “Pursuing Perfection in Health Care.”

Finding ways to help patients better manage their chronic diseases and navigate their way among various health care providers became the focus of Whatcom Countyís initiative. Early on, it was decided that only by directly involving patients in all redesign efforts could effective solutions be developed.

“The dynamic changed when the patients were at the table making decisions about changing the process of care. After all who really is the expert on what the patient would want?” said Mary Minniti Project Manager for the Whatcom County Pursuing Perfection Initiative.

Rebecca Bryson was one of the patients invited to participate.

“They made it very clear that we could just tell them the truth. And it was a level playing field. And there were lots of times that I was hesitant, but I needed to say — you know what? — that doesnít work for patients. Youíre making it harder. Itís making it easier on the system, but harder for the patients, said Bryson.

Rebecca BrysonNot surprising to Minniti and her colleagues, Bryson, and others participating in the Initiative, confirmed two primary concerned: patients are keenly aware of the lack of coordination in care; and they face a complex and often confusing delivery system.

To address these concerns, a new type of health care provider was developed Ė the Clinical Care Specialist. The Pursuing Perfection grant allowed for the funding of two Clinical Care Specialists in a pilot program. They work directly with patients — each has a caseload of about 50 — to help coordinate communication and care among a variety of providers and institutions

“Iíve had a number of times where I literally thought I could die today. At those times without the intervention of Nancy, my Clinical Care Specialist, thereís no question in my mind I would not have survived that day,” said Bryson.

The doctors equally appreciate the benefits of the Clinical Care Specialists.

“Clinical care specialists provide two incredible services. The first one is the most obvious, which is helping a primary care provider and a specialist, or multiple specialists, understand whatís happening on either end. Theyíre also able to convert what we say into language the patients can understand so they know what their own responsibilities are,” said Dr. Peter Beglin, Medical Director, Cardiovascular Center St Joseph Hospital.

To further address problems in communication and coordination, Whatcom County has developed the Shared Care Plan. This single record includes all relevant information about a patientís health, including medications, physicians, and current and previous health conditions. The patient maintains their own copy of the Shared Care Plan, and all providers can have access to an electronic version.

“At the very beginning of this project, I had just been diagnosed with heart failure. I was really sick and I was having a lot of days where I didnít know if I was going to survive that day. And I thought if something good could come out of this condition thatís what I wanted to have happen,” said Bryson.

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