Telephonic Wellness Partnership with Health Services a Model for Integrated Care
Posted 07/01/2011
One woman did not know the difference between a rescue and daily inhaler – a distinction that could mean life or death for someone in the grips of an asthma attack.
Another man recently diagnosed with diabetes didn’t know how to check his blood sugar, which also could prove fatal.
A mere visit to a primary care physician and a little education would help most patients manage these conditions and live a relatively normal life. But those who also suffer from a mental illness can require extra attention.
A new model of integrated care is being offered to mental health clients of AspenPointe and a pilot group from other Colorado behavioral health organizations.
“Sometimes people struggling with mental illness do not have the motivation to take care of themselves,” said Rebecca Bailey, a registered nurse and care coordinator for AspenPointe Telecare. “We help motivate and educate clients about how the two affect each other. If they go for a walk each day, it not only helps their mental health, but also helps with diabetes and asthma.”
Bailey is leading the outreach effort to Medicaid clients living with a dual diagnosis mental illness and any of three qualifying chronic conditions: Type 2 diabetes, asthma, and/or congestive heart failure. Of the clients Bailey has contacted, 82 percent have signed up for the telephonic support.
Her main role is to offer educational support regarding the symptoms and treatments for the conditions. She also facilitates communication between mental health and primary care providers.
“The overall response has been one of gratitude,” Bailey said. “Most of our clients are overwhelmed with mental illness and physical conditions, and they don’t know where to start or what to do.”
Bailey speaks with each client on a regular basis as determined by client need. Clients are typically enrolled in the program for six months. Regular contact with the client’s health care providers is important. But sometimes, others need to be involved.
“A client I contacted informed me that she stopped refilling her medications because of the cost. We were able to refer the client to case management for financial support,” Bailey said. “This is a great example of how the support works.”
Care managers, like Bailey, utilize evidence-based motivational interviewing techniques in all phases of client contact.
“The key to success in this process is validation of the difficulty of behavior change; developing concrete, measurable and attainable goals; and finding at least one positive client behavior during each follow-up contact,” said Robin Anderson, AspenPointe Telecare program manager.
Before coming to AspenPointe, Bailey worked as hospital nurse and served people when they were at their sickest.
“It’s nice to be on the preventive, early intervention side. In many cases, we are able to help people learn how to prevent or slow disease progression so that they don’t spend so much time in the hospital.”,” she said.
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