For a patient experiencing a medical problem, navigating the health care system can often be as challenging as the treatment itself. From scheduling appointments to setting and reaching goals, it is common for individuals facing chronic diseases or social barriers to feel lost or left out.

That’s why for much of the past decade, Olmsted Medical Center has continued to expand its use of care coordinators. These professionals, many of them registered nurses, work with patients one-on-one to help them better manage their health needs.

“Health literacy is a big deal,” explains Laura Oelkers, a care coordinator at OMC. Laura’s primary responsibilities are to assist patients with “understanding their medications, why they’re going to an appointment, what that appointment entails [and] what the recommendations are.”

Adds Laura, “There are a lot of people who get a lot thrown at them with a chronic disease … and they don’t really know how to put that together. Our job is to bring it all together and to make sure they’re being compliant and safe with their care.”

Laura Oelkers / Photo by William Forsman

An advocate for the patient

One common problem in health care is the public’s reliance on the emergency room as primary care. Not only does it put a strain on the hospital, it can set the patient back in their journey toward better health. Trips to the ER may be avoided by educating the patient on the use of other available, appropriate services such as Acute Care, FastCare and eCare.

By having a care coordinator accessible to them, patients have a trained expert who can listen to their needs and then direct them toward the right resources.

“Most of the time people are very grateful to have an extra person, or a go-to person to be a liaison, or an advocate for them,” says care coordinator Lindsay Paukert.

Setting goals

To get a patient on the right track, care coordinators begin by doing a complete assessment of the individual. That includes reviewing their medications, checking for chronic diseases and seeing if there are any social factors affecting their health.

“[We’re] taking a look at everything from their social support to their financial support to how many health care providers they have,” explains Laura. “So we’re taking a look at the big picture and what really is needed.”

From there, coordinators work with the patient to set goals tailored to their individual needs.

Lindsay Paukert / Photo by William Forsman

“Your diabetic numbers are poor; what can we as nurses do to get that down? You haven’t seen a diabetic educator? Let’s get that referral done. You need more education or maybe you need a nurse at home to help you with things? We can help set that up,” adds Lindsay.

While some patients, such as those with mental illness, may need extra continued support, the ultimate goal for coordinators it to equip patients with the knowledge and resources that allow them to become independent in managing their health.

“I love it when patients call you with their own solutions,” says Laura. “Now they feel like they have the power to make a positive decision to make themselves healthier.”

Overcoming social barriers

For many patients, the biggest obstacles toward improving their health are outside the scope of what a nurse or physician may be able to offer. This is where Abe Segovia comes in. Abe is a trained social worker and a recent addition to OMC’s care coordinator team.

Take a patient with diabetes, Abe explains. Perhaps they are having health issues because they can’t afford the insulin, or they can’t afford the machines. Or they don’t have enough money for food, so they’re making poor choices to eat not as healthy foods. Or they are missing appointments, because they don’t have adequate transportation.

In this scenario, setting goals or making a referral may not be enough. The patient may need assistance in finding the community resources that allow them to access health care.

“There’s a lot more that affects health care than you think,” says Abe. “ It can be getting the right resources to them — housing resources, transportation resources — and really working hand in hand with them.”

And just like with Lindsay and Laura, it’s about putting the patient in a position where their support is no longer needed.

“The way I gauge how effective I really am is if I don’t have contact with them anymore,” says Abe. “Because if I’m doing my job well, then I’ve set them up with enough plans, enough resources and avenues, and that they’re using them correctly and not reaching back out to me.”

This article is part of a series sponsored by Olmsted Medical Center.

Cover photo by William Forsman