Progress in DAWN Care Coordination

I wrote in March about the grand opening of our student run DAWN health clinic. It’s been five months and our clinic has been open every week. Over one hundred and fifty patients have come in, unable to go anywhere else but an emergency department. We continue to have hundreds of students volunteering, smiling and learning to be better health care providers!

The new Dayton Street Opportunity Center with open doors

The new Dayton Street Opportunity Center with open doors

Our Care Coordination (CC) division has worked hard to initiate a trusting relationship with every patient. We’ve made progress figuring out how to coordinate and track our patient’s health care needs and usage. Tracking the status and to-do list for each patient continues to be a challenge. We have experimented with tracking each patient’s needs through paper checklists, web-based databases and multiple spreadsheets. We have a low budget electronic health record (EHR) and have found that if we put too many notes or tasks into it we are faced with a safety issue of task saturation. It is essential that we receive results when we send a patient for a CT scan or samples to the lab. We’ve had awesome success enrolling dozens of people in Medicaid. Unfortunately, partly because of a budget EHR, I spent the morning sorting fax and privacy issues while forwarding a patient’s records to a Medicaid health clinic. Our CC has mostly been done on clinic nights with a few students making the necessary follow up calls during the week. This is necessary and we will continue to have CC at clinic night. This model is somewhat reactive, however, and we need a way to proactively impact our population’s health. CC continues to be a work in progress but to maintain our community’s trust our team must be following through for our patients.

Patient health will be better if we can coordinate healthcare and community.

Patient health will be better if we can coordinate healthcare and community.

I’m thrilled to say that we are moving forward with a new plan called Longitudinal CC! We have recruited a number of enthusiastic students from many schools that are interested in building a longer-term relationship with our patients and their families. Each student will become the primary CC for a number of patients based on their available time. They will be responsible for periodically checking in with the patients and guiding them towards regular preventative health measures like flu shots. Coordinators will help them navigate through both the complex healthcare systems and also to any community resources they might need. We believe that our longitudinal coordinators will help improve the long-term health of our DAWN patients.

I am amazed and thankful for the volunteers who have put in many hours developing this program. We’ve sorted how an English-only dental student can reliably call our Spanish-speaking patients. There is an easy how-to guide for our undergrad students recording their patient conversations in the EHR. Team members have assessed our patients for both risk and coordination needs so we can split them equitably amongst our coordinators. Our current tracking spreadsheet has been tested in the clinic and we’ve established a secure e-mail, phone and fax network for communicating amongst our team. We’ve presented the board members of the clinic with a “scope of practice” for our team that lays out not only the roles and goals but also the legal and safety limitations. Finally, we’ve brought each coordinator in to the clinic and introduced them to our culture while providing enough training so that they are comfortable and confident.

We will provide a more front-line and active learning opportunity.

We will provide a more front-line and active learning opportunity.

This model is also designed to provide a unique and awesome training opportunity for our team members. They get to see how a family navigates through the entirety of the care systems. Do they skip treating their urinary tract infection because they are uninsured and more concerned with buying enough groceries? For the soon-to-be community pharmacist, family doc or local physical therapist, building lasting patient relationships within the community is absolutely essential. We’ve recruited several younger undergrad students hoping to get into health schools soon. They recognize that this program will provide them great experience and stories for when they apply to future schools. Most of the CC can be done remotely at times that fit a student’s schedule. This model offers our team members a chance to succeed and to make mistakes in a safe and supervised environment before they find themselves on their own.

We are mitigating the possible risks of this new program by starting with a pilot program. We have chosen four personable, reliable and eager volunteers and given each five patients. They’ll start by calling their patients to see how they are doing and to introduce both themselves and the program. We have suggested guidelines but purposefully not scripted their calls. We hope this provides enough structure for consistently excellent care but also enough free space for them to use their own style in adapting to each patient’s needs. We’ve armed them with our intent and look forward to seeing what techniques worked, what lessons are learned and what questions are asked. Hopefully, in 3-4 weeks we will be able to fine tune the program and expand it to all of our volunteers and patients.

PlanCThere is still much to be done in the next weeks. We have gone through plans D, E and F but continue to improve. It has been awesome to watch and help our teams come up with creative solutions and programs! I am hopeful that we will be able to report some of the many successes of our longitudinal coordinators in upcoming months.


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