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Feature Article "Connecting the Dots" to a New Level of Care

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While today’s modern world brings us advanced health care and innovative approaches to healing, it can sometimes be a complex system to navigate. A surgery, a visit to the emergency department or even a lack of housing can further compound the issue, making it confusing and overwhelming for some people seeking medical services.

With a mission to enhance community health across the spectrum of care, Samaritan Health Services is strengthening the care coordination network and connecting the dots to make sure patients know who to turn to or which path to follow, every step of the way.

New hospital discharge planning programs, home visits, expanded roles in the primary care clinics, greater community connections and enhanced communication among all facets of the care continuum are essential components of this new model of care. With all of these in play, resources are being mobilized to continually guide and monitor patients, even outside of hospital encounters and clinic visits.

“It’s important for us to never lose sight of the patients’ goals despite how complex health care might get,” said Glen Cunningham, Samaritan’s vice president for population health. “By providing more wrap-around care we can simplify the process, guide them through and make it more human for them.”

Stemming from the concept of a patient-centered medical home (PCMH), this enhanced model of care coordination takes it to a whole new level. Not only is patient care coordinated and delivered within the PCMH, but now it’s being deployed outward to wherever the patient is located — whether that be in the hospital, a clinic, at home, in a skilled nursing facility or in the broader community.

“Another big part of our care coordination network includes a new level of collaboration and communication with outside organizations and community partners,” said Cunningham. “We never want to lose sight of the patient, and these connections ensure that we can keep track of where the patient is in their care plan and help guide them through.”

Part of this enhanced communication comes from new and expanded uses of the electronic medical record, including a new longitudinal plan of care (LPOC) put into place at the beginning of this year throughout Samaritan’s entire service area. The plan provides a snapshot of a patient’s medical history, their personal health goals and how caregivers can help them get there. Now, anyone in the care process — from primary care providers to therapists to care coordinators to skilled nursing facility personnel — can all have visibility to the LPOC at any time, allowing for quicker and more seamless communication regarding patients and their recovery.

This more inclusive process provides a humanistic approach by walking with them through their health care journey. In the end, it means better care and improved health for the patient, fewer hospital re-admissions and emergency department visits, and most importantly, it lets patients know they aren’t alone.