National Jewish Health Helps Underserved Navigate Health Care System

Press Ganey Presents Award Recognizing Teamwork and Care Coordination

Press Ganey Associates, experts on patient experience in health care, has awarded the National Jewish Health Comprehensive Respiratory Care Clinic (CRCC) its Team of the Year award for outreach and coordination of care for underserved patients. Funded by a three-year $1 million grant from Kaiser Permanente Colorado, a multi-disciplinary team of caregivers in the CRCC helps homeless and working-poor patients access, understand and participate in their own health care. The CRCC team has reduced missed appointments and improved patient satisfaction while providing comprehensive specialty care that helps reduce health inequalities.
 

“Health care doesn’t happen just in the doctor’s office,” said Elizabeth Johnson, RN, nurse-case manager for the CRCC. “We reach beyond the clinic walls to help patients with a whole host of issues so they can get health care that allows them to live fuller, healthier lives.”

The complex, often fragmented American health care system can be daunting to navigate for anyone. Homeless and the working poor face many additional barriers to effective care including lack of transportation, financial burdens, lack of continuity of care and incomplete communication and education. The CRCC team at National Jewish Health helps those underserved patients gain access to effective care with a team approach and extensive outreach, especially by patient navigators.

Patient navigators help patients overcome a wide range of medical and non-medical barriers to care. They make reminder calls to patients for upcoming appointments and diagnostics, help arrange transportation, find affordable medications, assess and review medication inhaler technique, coordinate follow up visits and diagnostic testing, and partner with patients’ primary care providers. As the team member with the most contact with patients, patient navigators communicate with other CRCC team members about any issues and coordinate care among the team.

“We’re part medical assistant, part patient navigator. Sometimes we’re social workers,” said CRCC patient navigator Brittany Lee. “There are so many ways to help.”

The CRCC team also makes sure that patients’ primary care providers receive rapid communication about a recent visit through a Quick Summary Note, which contains key information about planned diagnostic tests, new medications and brief directions for follow up care. They also meet regularly with referring safety net clinics to improve communication and coordination of care.

Patients served by the CRCC have typically missed almost half their appointments in the past. That number has dropped to around 15 percent with the new program. Patient education occurs during more than 90 percent of visits. Patient satisfaction also improved markedly rising from 3.2 on a one-to-five scale to 4.8. Favorable ratings from providers have risen from 2.8 to 4.3.

The Team of the Year award was presented to National Jewish Health November 1 in Orlando, Florida, at the Press Ganey 2017 National Client Conference. The program is funded by a $1 million three-year grant from the Kaiser Permanente Colorado.