During a home visit, nurse case manager Kelly Holliday spotted the culprit on her patient’s kitchen shelf. It was a Mason jar full of salt. The patient, already suffering from cirrhosis, had previously been rushed to the hospital by his family with painful abdominal fluid build-up known as ascites. After Holliday explained that high sodium intake caused this in cirrhosis sufferers, they understood that a change in diet was in order.
On her next visit, she’ll be checking if that Mason jar is still there.
Such house calls are common for Holliday, who along with physician Rita Miranda, MD and social worker Judy Lux staff a high-risk clinic in California’s high desert community of Hesperia. Partnering with Blue Shield of California, St. Joseph Health System established this clinic to provide personalized, hands-on care for their sickest patients.
Staff provide patients with knowledge and tools to help them manage their conditions for better outcomes and lower cost, reducing unnecessary hospital and emergency room visits. The clinic is located at the health system’s St. Mary’s campus and opened in April 2018. The establishment of the high-risk clinic is one component in Blue Shield of California’s Accountable Care Organization Core 4.
After patients are screened to determine if they are eligible for the clinic’s care, they develop a comprehensive treatment plan that addresses all aspects of their specific conditions. This can include any combination of specialty doctor treatments; home care and lifestyle management; and behavioral care. The clinic taps into the expertise of specialists within the entire St. Joseph Health System. Patients are often surprised that high-risk clinic’s care come at no additional cost and are part of Blue Shield’s coverage.
“We’re collaborating with the patient for a collective treatment plan,” explained Holliday. “It goes a little bit further than just making their appointment. It’s making sure that the patient understands the plan and is educated about their condition. We take time to answer their questions and figure out what their expectations are and make sure they have all the right tools to manage it.”
The high-risk clinic addresses the multiple factors that impact their patient’s well-being, and goes the extra mile to accommodate for the variety of unique circumstances of their lives. For a patient with no lower extremities, and unable to make office visits, clinicians make televisits so they can both see and hear the patient. For non-English speakers, they will use automated translation services. For the patient who is worried about the mounting electric bill her oxygen machine causes, they’ll find out find out that a local utility offers discounted rates.
The foundation for delivering such personalized care comes down to building an ongoing relationship with the patient as well as their families, many of whom are also their caretakers. The clinic remains in regular touch with them and Miranda, a long-practicing physician in the area, is a recognizable and trusted figure in the community.
“You can’t just build a rapport with someone on a one-time visit. I contact them weekly, or it can be every other day depending on how severe their conditions are,” said Holliday. “We’re a household name to every one of our patients.”
The clinic’s services are comprehensive and cover all aspects of care, including end-of-life care. One of the clinic’s first patients was a 56-year-old woman with neurological problems and un-managed diabetes. Through lifestyle management overseen by the clinic, specialty doctor treatments, and physical therapy, she was able to get her diabetes under control and was on the path to a healthier life. And like all their members, the clinic developed a special bond with her.
But a fall led to a severe head injury, leaving her with cognitive and physical suffering. She was brought in to the clinic by her husband, and after she made clear to the doctor that she no longer wanted to prolong the pain, she opted not to seek further medical treatment. Instead, the discussion focused on her end of life plan. She chose hospice care in her home, and died shortly after her accident.
“We took care of her, from the beginning of the chaos to the end of her days,” said Holliday.
Since then, the clinic has worked with other patients like her to help them understand their options. For the clinic, it’s just one of the unique and personal ways they’re able to care for patients at a high level, and an approach they hope to expand. The clinic currently manages 55 cases, with aspirations to double its size by the end of the year.
“It’s awesome to come to work every day and know we’re making huge impacts and making a huge change in somebody’s life,” said Holliday.