Health Care Homes Audiocast Ep. 1: Becky’s Care Coordinator Story

Health Care Homes Audiocast Ep. 1: Becky’s Care Coordinator Story


[Music] Anncr: Welcome to this audiocast produced by the Minnesota Department of Health, Health Care Homes program. Carol: Hello this is Carol Bauer from the Minnesota Health Care Homes program and we are here today talking with Becky Engdahl from the Mayo Clinic in Rochester Minnesota. Good morning Becky. Becky: Good morning Carol. Carol: Well I’m so glad you could be with us today and we’re here today to talk about care coordination. So let’s start by talking a little bit about your background and how you came to be a Care Coordinator. Becky: Well my Nursing journey started in critical care. I had a summer internship in a med-surg transplant ICU that led to a full-time position upon graduation with my Registered Nurse. And I spent 10 years there, and even from the start of my nursing career, I really valued the power of nursing and connecting with patients and families to improve overall health outcomes. I have the opportunity to have a temporary outpatient assignment in primary care. I spent five years in telephone triage and primary care team nursing, and after that time I had an opportunity to go into my current role which is adult care coordination in primary care. Carol: So it sounds like that patient connection, direct patient connection is really important to you. So, let’s talk a little bit now, about your clinic. Tell me about the people you see in your practice and in your community. What does that look like? Becky: My role in my area in Mayo Clinic is I work at Mayo Family Clinic in Kasson, Minnesota. This is the home of Family Medicine Residency Program for Mayo Clinic. It’s a growing rural community of about 50, sorry 6,300 people, 13 miles West of Rochester. And we support a population about 13,000 patients, from birth to grave. Carol: I think that that might be a surprise to some people, that Mayo has a presence in rural Minnesota, but it’s true. So how are you enrolling your patients, identifying and enrolling your patients in Care Coordination? Becky: Well, my role in Care Coordination has been adult chronic disease for the past five years. It is undergoing some changes. At this time, we’re going to start studying the effectiveness of Care Coordination roles in the reduction of hospital readmissions for patients with multiple chronic conditions. And being, that it’s a research study at that time our population will be determined by a registry based only. Carol: Registries are one of the challenges but you’ve had a lot of challenges along the way to building a robust Care Coordination story. Carol: So what do you remember as being, you know, especially challenging for your team and your patients, and what did you do to work through some of those challenges? Becky: When patients have limited access to their primary needs. It’s difficult to address or promote self management of their chronic conditions. I continue to feel blessed to have numerous resources here at Mayo Clinic, through Community Health Workers, both Clinic and Community or County Social Services, and there are several non-for-profit organizations out in the community that do partner with patients to overcome such barriers to health. Carol: That’s really great, that you have all that in motion. Can you talk a little bit more about some of your community partnerships? I think people would find that interesting. Becky: Mayo Clinic has a community partnership with a nonprofit organization in Rochester, called IMAA, to have Community Health Workers out here in primary care. They have been an incredible valuable resource we had in the last couple years, to connect patients with these Community Health Workers, that are able to meet with them one-on-one and kind of help guide them to what community resources are available. Carol: Great that you’ve been able to get to that level, where you’re working with your community. If you talk a little bit about how Care Coordination has changed your practice and what are you learning as you continue to evolve? Becky: Well Motivational Interviewing has been an effective tool, that I learned through my role in Care Coordination and this has changed how I communicate, how I promote discussions on behavioral change in my professional, and in my non-professional life. Communication with Motivational Interviewing, can help uncover their story, and help provider and patient discover that, the inner motivation for behavioral change. And so, throughout my time in Care Coordination, I continue to learn and improve my technique with this skill. Carol: Looking back, what advice would you offer to clinics that are early in their Care Coordination journey? What do you know now, that you wish you’d known when you started? Becky: So my advice to those early in their Care Coordination journey: network, find your team, don’t be afraid to reach out to specialists to community activists, anybody who can help find the answers. For instance, when I was very new in the Care Coordination role, I was paired with a complex COPD patient that led me to a friendship and a partnership with a COPD Inpatient Respiratory Therapist. And five years later, she is still one of my go-to people, when I’m struggling on what to do with patients with complex COPD that we’re working to improve their management with. Carol: So well, that’s all I’ve got for you today Becky. But thank you so much, for sharing your experiences with us and your wisdom. This is our very first podcast, Health Care Homes stakeholders and we are looking forward to bringing you more in the future. So this is Carol Bauer, from Health Care Homes, signing off. Thank you Becky. Anncr: Please visit the Minnesota Health Care Homes website for more resources to help you deliver, a patient-centered team-based care. Thanks for listening. [Music]

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