Care Managers- Navigators of Health Care

For many patients, navigating the health care system, including insurance and public assistance opportunities, is confusing. Even under the best of circumstances, a patient diagnosed with a chronic disease or illness can often feel overwhelmed. Additionally, if patients are also experiencing a financial crisis or homelessness or simply lack familial support, they can be especially vulnerable.

Outpatient care managers.

Meritus Health has established an invaluable team of outpatient care managers that provides support for patients with self-care, disease management and health system navigation.

Deb Thompson, B.S.N., M.H.A., RN, director of outpatient care management at Meritus Health, explains that the team’s primary purpose is to help patients better manage their health. “For instance, if a patient’s diabetes is not well-managed, a physician can refer him/her to our team,” she says. “A care manager will meet with the patient one-on-one, develop a trusting relationship, identify specific strengths and barriers to self-management and work collaboratively with the patient to set individual health goals.”

It takes a village.

In addition to nurse care managers, the team includes respiratory therapy educators, social workers, diabetes educators, behavioral health therapists, community navigators and community health workers.

Depending on a patient’s needs, the care manager can bring in these other members of the team to help create a customized care plan for that individual patient. This same care management team will work with the patient at his/her primary care provider’s office.

Patients may be able to be connected to community resources, financial assistance, housing, transportation options and health insurance with the support of the team’s social workers. Community health workers from the team are available for some patients who require weekly home visits for additional support and monitoring.

No extra fees for service.

Approximately 1,300 patients each month are supported by outpatient care management team members at Meritus Health.

“This service is offered to patients at no charge to them or their insurance,” says Thompson.

By removing the financial barrier, patients can receive the education, monitoring and support they need to improve their health.

“Oftentimes, we are following up with patients weekly,” says Thompson. “If their needs are more urgent, we will reach out more often.”

Thompson says that as patients develop confidence, contact by the care managers may become less frequent, but “we are always available.”

Ask your health care provider.

Services offered by the outpatient care managers are available to all patients of Meritus Medical Group practices. A patient should simply ask when he/she is in for an appointment.

“Many patients are not aware that our team exists at all and are therefore, not leveraging the services and support we can offer,” says Thompson.

“As care managers, we can help patients reach their personal health goals; work to reduce the number of visits they make to the emergency department for non-emergent care; help prevent unnecessary hospital admissions and re-admissions; and teach them how to navigate the health care system in a more effective way to have a better patient experience,” says Thompson. “We are here, ready to help and hope more patients will talk to their doctor or provider to learn more.”