Network News 2021, Volume 2

Meeting Patients Where They Are to Improve Health Outcomes

Asante’s primary care “Clinical Core Teams” play a critical role in advancing Asante Health Network’s mission to reduce health care costs and improve quality of life. Their work is foundational to delivering value-based care.

Asante Core Team Activity January 2021 - August 2021

Asante Core Team Activity  |  January 2021 – August 2021

Who makes up the Clinical Core Teams?

  • Nurse Care Managers play a key role in developing individualized care plans for patients and helping them to learn to self-manage their chronic conditions.
  • Community Resource Coordinators address patients’ social determinants of health such as housing; activities of daily living; food and financial insecurities.
  • Behavioral Health Consultants address acute and chronic mental health needs and facilitate referrals to therapy providers and rehabilitation programs.

Why do the Clinical Core Teams exist?

  • To expand access to care: From October 2020 to January 2021, nearly 1,500 patients received care from the Clinical Core Teams.
  • To enhance the health of our community: The services provided by Clinical Core Teams address a wide range of medical and social needs including housing, health insurance, financial, food, transportation, caregiver needs, education, transportation, access to clean water, and community safety.
  • To deliver better care at lower cost: For patients receiving services from the Clinical Core Teams during August and September 2021, the rate of inpatient utilization met the reduction target (127 inpatient days per 1,000 patients), while the emergency department (ED) utilization was well below the reduction target (156 ED visits per 1,000 patients).

Making a Difference: One Person at a Time

The services provided by the Clinical Core Teams can be life-changing.  One example is Hector (not his real name), a 53-year old patient admitted to Asante Rogue Regional Medical Center with COVID-19 at the end of October 2020. Hector had been living in a hotel room since losing everything he had in the Almeda fire the month before. He had also been recently diagnosed with Type 2 Diabetes.

The following month he was admitted once again with the development of a foot ulcer and had lost his job during that time. He had seen his primary care provider who referred him to one of the Clinical Core Teams for assessment. By December, Hector’s Clinical Core Team had helped him:

  1. start using a blood sugar monitor and pill pockets for better medication adherence.
  2. secure health insurance.
  3. receive further benefits and care assistance through the state of Oregon Department of Health Services.

By early 2021, Hector was receiving FEMA assistance and pandemic unemployment benefits, and was engaging in ongoing diabetes treatment with his PCP. Our team was also able to help him secure long-term housing. His health goals are now on mental health, diabetes control, and fall reduction.


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