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Medical team approach

Medical home providers at Sanford Health include (left to right) Dr. Knute Thorsgard; Pam Halvorson, LPN; Colleen Bauck, RN health coach; and Dr. Ram Kafle. Photo by - Vicki Gerdes

It only makes sense that keeping a lid on the rising cost of health care begins with keeping people healthier -- and with its new Medical Home program, Sanford Health-Detroit Lakes has made an even greater commitment toward doing just that.

Medical Home is a program that offers team-based, coordinated care, focusing on the whole patient rather than one specific aspect of their overall health needs.

"Our first patient was enrolled (in the Medical Home program) in April," said Colleen Bauck, R.N., who was hired as a health coach for the Medical Home program at the Detroit Lakes clinic in February.

Since then, she and the staff at Sanford Health-Detroit Lakes have been working toward the process of becoming certified as a "patient-centered medical home," Bauck said. "We were just certified by the Minnesota Department of Health last Friday (Dec. 14).

What certification means, she added, is that the Detroit Lakes clinic has now met a strict set of criteria for quality and performance in providing team-based, patient and family-centered care.

To become certified, Bauck said, "We had to change the way we think about health care, and the ways we're delivering it."

Patients are treated from a whole person perspective, rather than just looking at the specific medical issue that brought them to the clinic.

"It helps us be more prepared, and proactive," Bauck said, adding, "The old model was more reactive and chaotic."

As an example, a patient enrolled in Medical Home might come into the clinic for acute care, such as for an injury or virus, but the doctor will also assess their progress in treatment of a chronic illness or medical condition as part of the same appointment.

"Our goal is to improve patient outcomes, to decrease acute care visits and increase preventive care visits," Bauck said. "Ultimately, our goal is to keep them healthier ... to keep them out of the hospital."

Under the Medical Home model, a team-based approach is taken to the patient's health care.

Each patient's care team includes at least one primary care provider, the RN health coach, specialty care providers, clinic staff and family members -- with the patient as an active participant.

"Basically, we're engaging our patients in their own health care," Bauck said.

Participation in the program is voluntary, Bauck said, but candidates who are recommended for Medical Home by their primary care provider usually meet one of the following criteria:

• Multiple and/or chronic illnesses

• Unstable or newly diagnosed illness;

• Taking multiple medications;

• Special health needs.

"The patient always has a choice -- they have to agree to participate," Bauck said. "A patient can also request to be enrolled if they feel they are struggling with self-management or they do not have the support or resources (to manage their own health care) ... a family member can request it too."

Once a primary physician has discussed the benefits of enrolling in the Medical Home program with the patient, they will usually introduce the patient to the RN health coach.

"My initial visit with patients is fairly lengthy,' Bauck said. "We look at multiple factors -- their lifestyle, past medical history, medications they're taking, any specialty care providers they're seeing, and what they're currently doing to manage their care at home."

The visit may also include a discussion of financial concerns they may have, any psychological or behavioral health needs they may have, and any barriers that may exist toward receiving good preventive care.

"We talk about what their risk factors are, what the physician's concerns are, what the patient's concerns are, and set mutual goals, so the patient has a role in setting up their own care plan," Bauck said.

The goals set at that first meeting are small, easily measurable and achievable.

"We start small, with baby steps," she said. "When they reach their goals, we set new ones. By making these goals achievable, we're not setting our patients up for failure."

Seeing a patient's excitement and pride in meeting those goals brings a great deal of job satisfaction for Bauck.

"It's very rewarding to see their smiles -- they're so happy to share their achievement with you," she said. "It helps them become more engaged or involved in their own care.

"I see a lot of people who are afraid to let their doctors down (by not meeting their goals). If they can prove they can do these small little tasks and meet their goals, it encourages them to take better care of themselves."

Follow Detroit Lakes Newspapers reporter Vicki Gerdes on Twitter at @VickiLGerdes.

Vicki Gerdes

Staff writer at Detroit Lakes Newspapers for the past 16 years, currently editor of the entertainment and community pages as well as covering city council and the Lake Park-Audubon School Board. Living in DL with my cat, Smokey.

(218) 844-1454