One Team, One Mission
Managing Chronic Illnesses Through Innovation
By Denise Fontaine
What if everything you needed to manage your chronic illness was in one place and easily accessible?
Edwin Menjivar is an active retiree who has had diabetes for the past 11 years. He comes from a diabetic family; his father had diabetes for 40 years, all five of his siblings are diabetic, and his nephew was diagnosed with diabetes at age 9. This time last year, Edwin was receiving care for his diabetes from another neighborhood clinic, and he says, “They were no good; they didn’t take care of me like this place. Here at CPMC, everyone worries about me in a way that makes them on top of everything that’s going on with me. The other clinic would cancel my appointment and not tell me until I got there, and I would have taken three buses just to get there. Here they call me the day before each appointment to remind me.”
Edwin has been a patient at California Pacific Medical Center’s HealthFirst for six months, arriving with a blood sugar level over 200 (anything over 150 is abnormal) and now his blood sugar level is between 75 and 80.
These days, many chronically ill patients like Edwin receive treatment in a health care system designed to deliver care for short-duration illnesses, such as the flu, resulting in problems with care coordination for those struggling with more long-term problems like asthma and diabetes. This disconnect drives innovation at CPMC’s St. Luke’s Health Care Center. “When I was at the other clinic, they never told me how to eat, and I used to eat a lot. Here, the nutritionist told me to stop drinking alcohol, and I haven’t had a drink in six months,” Edwin says, adding that he no longer eats tortillas, white rice, beans or red meat, and he feels good every day. He continues, “Everything is happy. I am very happy because my sugar is not high anymore and the doctor’s team I work with worries for me.”
The HealthFirst Project
CPMC’s St. Luke’s Health Care Center’s response to the changing needs of patients with chronic illnesses is the HealthFirst Project. HealthFirst is led by a multicultural, multidisciplinary medical team; a nurse coordinates case management, a social worker provides referral and counseling on psychosocial issues, and a community health worker serves as an educator on behalf of the physician. In doing so, the community health worker provides patient navigation, addresses cultural and language barriers, and monitors the patient’s self-management skills. At HealthFirst, the community health worker and the patients work together to improve the patients’ confidence in understanding their medications, using testing devices for their blood sugar levels or asthma, and recognizing environmental triggers.
”The goal of HealthFirst was to see if we could take people from the community with limited or no background in health sciences and train them to work with a clinical team,” explains Russell Lee, Ph.D., director of Health Systems Innovation at CPMC. The trusting relationship created by the team approach enables the community health worker to serve as a link between health services and the community to ease access and improve the quality and cultural competence of their care. HealthFirst believes that if a patient is taught valuable self-management tools, he or she will better understand his or her own disease and become proactive in taking control of it, making the long-term changes needed to improve his or her quality of life. A team of four (two nurses, a dietician and a community health worker) helps keep Edwin’s diabetes under control.
HealthFirst first started delivering care to patients in 2007. The program continues to increase access to primary care to uninsured or underinsured San Francisco residents with chronic illnesses such as asthma or diabetes. Through a model that focuses on preventative care, outreach, and education for health self-management, HealthFirst hopes to improve health of the chronically ill and also reduce the impact of preventable emergency room visits. To find out more information about HealthFirst, you can call 415-641-2160 or visit the HealthFirst Project page.