KRH seeing results from care coordination program

David Dixon is no stranger to Kalispell Regional Healthcare’s emergency room.

Over a 14-month period he landed in the ER 42 times. Once an emergency medical technician and a hunting and fishing guide, Dixon, 53, was left with debilitating chronic pain from a motorcycle accident years ago, and struggles with other ongoing medical issues that cause pain and nausea every night. He also deals with mental-health issues such as depression and anxiety.

When Kalispell Regional tapped into a pilot program in 2016 aimed at improving patient care coordination, patients like Dixon were ideal candidates. In a nutshell, care coordination involves deliberately organizing patient care and sharing information among all providers with the goal of making care more efficient and effective.

“The goal is to improve patient outcomes,” said Lesly Starling, a registered nurse and the complex care coordinator for Kalispell Regional’s ReSource Team.

In America, 50 percent of health-care spending involves just 5 percent of the population. It’s a startling statistic that drives home the need for coordinated care.

Starling spoke about navigating complex care at a recent Transition of Care Summit at Kalispell Regional Healthcare. The conference drew care providers from throughout the state and offered continuing education credits for nurses.

“People from other cities are trying to learn how we’re making this work,” she said.

During the conference, Dixon and other patients with complex cases told their stories and the difference care coordination has made in their lives. The bottom line: care providers are seeing results.

“After they got me figured out, I’m now down to 13 trips to the ER in a year,” Dixon told the group. “These ladies helped me. They figured out you need to get doctors to talk to each other.”

Dixon also was featured in a PBS News Hour television segment that aired last year about Kalispell Regional’s experience with the pilot program funded with a federal grant through Mountain Pacific Quality Health Foundation, along with funding from the Robert Wood Johnson Foundation.

“I just want to have a better life,” Dixon said in the PBS segment. “I’d like to wake up in the morning and have a half-decent day. I’d like to make plans for tomorrow morning.”

The show focused on Kalispell Regional’s ReSource Team and explained the goals of reducing ER visits and readmissions while increasing appropriate primary care provider visits and patients’ self-perception and self-management skills.

In Dixon’s case, the news segment explained how a coordinated team helped him reconnect with a pain specialist and a pharmacist to sort out his medications.

Care can get “watered down” the further removed providers are to complex-care patients, Starling said. With more involvement from all of a patient’s providers, the more relevant care becomes, she said.

Sheran Greene, who has chronic lung disease and was homeless for a time, was another local patient who shared her story, both for the PBS show and the Transition of Care Summit. She cycled in and out of the ER — “I was there like clockwork,” she said — sometimes just to get out of the cold, or to get access to an electrical outlet to charge up her oxygen machine.

In one six month period; Medicare charges for Greene’s care topped $100,000. By coordinating care, the cost was whittled down to about $6,000.

The care team, which includes help from local resources such as ASSIST, a local nonprofit that connects socially and physically isolated community members with services, found Greene an apartment and helpers now deliver her to her primary care doctor for check-ups.

Greene said dealing with the stigma of being homeless was an added burden to her medical challenges.

“Unless you’ve been homeless you don’t know how much that pride takes a hit,” she said. “We shouldn’t label all homeless as lazy because most of us aren’t.”

Starling stressed the importance of not losing sight of the value and human dignity of each patient.

Features Editor Lynnette Hintze may be reached at 758-4421 or lhintze@dailyinterlake.com.