Case Study: Care Coordination
Based in the health plan’s local area, Outreach Coordinator Sally Brown also participates
in Clinical Collaboration. Armed with a greater understanding of John’s situation,
Sally goes into action to engage John in the Synergy program. Having worked in the
community for some time, Sally had previously established linkages with John’s homeless
shelter and had educated the staff on the Synergy program.
After several attempts, Sally meets John at the shelter. Sally explains the Synergy
program and directly connects John with a personal, dedicated Synergy Care Coach.
Through Care Coordination John is also referred to a multi-crisis center and, once
stabilized, enters a group home.
As John works with his coach, he becomes more motivated to proactively address
his health and life issues. He becomes more cooperative with group
home staff who are assisting him in consistently adhering to his medication
regimen and more receptive to working through Diabetes and Psychiatric self-management
information with his Care Coach. He also begins taking advantage of an opportunity
to receive vocational training and ultimately to become employed.
Through Clinical Collaboration that includes his PCP John is referred to a local
Diabetes Self Management Education Center. John is initially hesitant, but with
his Care Coach’s encouragement, he makes it a goal. As John becomes more self-efficacious
the fluctuations in his insulin wane, his psychiatric condition stabilizes, he feels
more confident and his health improves. Because of his stability and understanding
of his condition, an appointment with an endocrinologist has been secured and he
is under consideration for an insulin pump.
John has not utilized in-patient or emergent health care services
in the seven months so far that he has been in the Synergy program.
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