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Core 4 Stories: How Blue Shield Took the High-Risk out of a High-Risk Patient

Blue Shield of California and its accountable care organization (ACO) providers have implemented an advanced clinical model called the Core 4, focusing on the components of an integrated and optimized care delivery system.

A 66-year-old morbidly obese Blue Shield of California member struggled with high blood pressure and type 2 diabetes. His A1C level – which measures a person’s blood sugar level – was at 8.5 percent, dangerously higher than the normal range of 4.5 percent to 6 percent.

Christine de Belen-Wilson
Christine de Belen-Wilson

But thanks to a care management and coordination program we’ve implemented with our ACO provider Dignity Health, we helped this Ventura County resident tackle a dangerous health condition in a timely way. The program is part of Blue Shield’s “Core 4” effort, which looks at four key clinical models to greatly enhance quality of care while making care more affordable.

The Ventura County member enrolled in Dignity Health’s Ambulatory Care Coordination program. It provides personalized outreach to patients who have serious medical risks through in-person and telephone support. In this case, Dignity Health’s care coordinator provided education and an action plan to help the patient adopt healthy eating habits and increase his activity level. Within seven months, this patient had lost 65 pounds, his A1C dropped to 5.8 percent and he no longer needed to take medication to manage diabetes and high blood pressure. 

This is just one example of the positive outcomes emerging from Dignity Health’s Ambulatory Care Coordination program, which provides dedicated healthcare teams to high risk patients. The program is available at no additional cost to Blue Shield members and provided in collaboration with the Southern California Integrated Care Network in Ventura County (SCICN). SCICN is led by a dedicated group of physicians that works with local hospitals to ensure patients receive the highest quality care and physicians get the tools and resources they need to improve their patients’ health.

In addition to the group of physicians, SCICN has a staff of care coordinators – registered nurses who have access to a wide variety of resources including clinical and social services. They provide individual personal support and assistance to high-risk and rising-risk patients who face issues such as:

  • Two or more chronic conditions
  • Multiple medications and/or high-risk medications
  • Multiple emergency room visits and/or hospitalizations
  • Social barriers – for example, living alone without caregiving assistance

Care coordination managers help patients monitor medical appointments and office visits; and assess the patient’s adherence to medications and potential medication risks. These managers also help assess whether other professionals, such as a social worker, should be part of the patient’s support team.

As a nurse practitioner, I’m especially proud of this program and the way I can work closely with my colleagues at Dignity Health to make a real difference in the lives of Blue Shield of California members. When it comes to building a successful care coordination program such as this, it takes a team of like-minded organizations and individuals to make it a success, and we’re proving that to be true.