duties for Hospital employees
St. Mary’s and Clearwater Valley Hospital and Clinics are working on a Patient-Centered Medical Home concept where patients form a partnership with a personal primary care physician who leads a team of professionals dedicated to providing proactive, preventive and chronic care management through all stages of life. Medical Home ensures quality and continuity of care.With the development of this new concept came some new duties for two of St. Mary’s employees; Julie Church, RN and Ralyn Horton.
Julie Church will now be a RN Case Manager. Working with the patient, family and physician, Julie will develop an individualized care plan for those patients most in need of this service. Medical and social needs and family circumstances will be assessed and incorporated into the care plan. Julie will take direct patient calls, work frequently with high-risk patients, make sure patients are current on lab testing and screenings and respond to physician requests to coordinate community services like home care and patient teaching. “I am excited to be involved in a process that will help provide the best care possible for our patients,” said Julie. “The ultimate goal of this service is to improve the quality of life for our patients.”
Ralyn Horton will be serving as the new Referral Coordinator. Referral coordinators coordinate specialty physician and community resource consults as recommended by the patient’s provider. Ralyn will help patients who need to go to other facilities for more tests or procedures by setting up the appointments, sending appropriate information and helping with any follow-up services.“I am very excited about my new duties,” said Horton. “I will be able to take some of the load off our doctors and nurses by helping with phone calls and the referrals.”
These new positions were made possible by a three year federal outreach grant which was secured by Pam McBride, grant writer for St. Mary’s Hospital and Clearwater Valley. “This is going to be a great opportunity to unify all the wonderful community resources we have to help some of our sickest patients,” said McBride.
This program will focus first on some of the highest-risk patients; these patients will receive a letter asking if they would like to be part of this Medical Home Program.