Stephanie King, a care coordinator with Castell who works at West Valley Clinic, had initially called the patient and his wife as a reminder for their annual wellness visits. The clinic follows the Reimagining Primary Care model to give high risk patients better care management and patient experience by making sure they get preventative appointments and follow-up. Stephanie says the patient was already on their radar, but she was worried when she learned he’d been taken to the hospital by ambulance.
“After the patient’s hospitalization and discharge, we continued to communicate with the family on his status,” says Jessica Zenter, care manager. “We learned the patient was deteriorating faster than expected. They wanted to revisit his goals of care and have an in-depth conversation about their options.”
As soon as Erin Helms, MD, a family medicine provider, found out the patient’s status, she took the initiative to visit him at home, along with her medical assistant, Juli Escobar, and Jessica, after an already busy day.
“This amazing team went the extra mile to make sure this family had everything they needed during a difficult time, including medical advice, insurance information, and the best way to care for their loved one,” says Stephanie. “I know they were extremely grateful for the visit. This is how we’re supposed to be thinking of our patients, like they’re family.”
“After we went to their home to offer support and answer their questions, the family decided together to change the plan and accept hospice care,” says Dr. Helms.“When he passed away a short time later, the family expressed appreciation for the care he received at the end of his life. After he passed, we were able to support the wife and daughter during their time of grief due to the rapport established at the previous visit.”
“This is a good example of teamwork at our clinic,” adds Jessica. “Even though the patient passed away, our team, led by Dr. Helm, made the effort to do what was best for this family, and especially for the wife and daughter, who needed the extra support.”