Article provided by Colorado Community Health Network.
Providers at Yuma Clinic in rural Yuma, Colorado treat about 1,000 patients per month on average. Serving a patient population that is about 40% Hispanic with a significant number of elderly, the Yuma clinic has close ties to its small community and the local hospital which helps for prioritizing care coordination.
Teri Mekelburg, R.N., says successful follow up and coordination of treatment after receiving care at the clinic is easier in a small community. The provider and nurse work together to make sure referrals are done to home health care, or other community resources with the help of a Community Health Worker who is employed by the hospital.
“Our community health worker does local outreach, and working through a grant for heart healthy solutions, she offers weight management classes and glucose and lipid screenings as a free service. Last year she conducted screenings on 300-400 patients,” says Mekelburg.
Mekelburg adds that when patients are discharged from the Yuma hospital, located in the same building, the hospital discharge planner coordinates with community resources and with the clinic so that a patient’s care team is notified of any emergency department use, for example.
“It’s nice because there is no dropping the ball between the hospitalist and primary care provider as happens in larger facilities. The provider that is seeing them in the hospital is the same one who normally will see them in the clinic,” she says. “The discharge planner would make a plan for patients to follow up with their PCP here. The same thing goes for the ED. If a doctor wants to see a patient again, then they will make an appointment at the time of discharge.”
A county-employed ombudsman is also available to assist patients with resources for care. “If we have someone who needs help with insurance or Medicare Part D sign up, our ombudsman conducts referrals to special services, including help with long term care options,” says Mekelburg.
Mekelburg adds, “We also have very low nurse turnover; so our nurses, who know the resources well, and the community health worker can work together to coordinate care between clinic, hospital, and home for the best patient outcome.”
