Care management services are provided by the McFarland Wellness program staff to multiple health providers’ clients through funding of the CMS’ Chronic Care Management Service. Given the intent and regulations of the federal program, the assessment and electronic documentation of each client is challenging but essential to obtain and maintain eligibility for the client.
Referrals for this Wellness program are primarily from health care providers providing a single health service, but the client has needs that far exceed the health care provider’s capacity; yet, if the client’s needs remain unmet, the client may deteriorate and require more costly intervention. An example is a cardiologist’s elderly and isolated client who needs regular blood pressure monitoring to maintain good health after surgery.
Case management under the CMS Chronic Care Management Service requires collaborative service provision. Because clients evidence a plethora of health and social risk factors, the Wellness staff have experienced in obtaining community-based services for specialized health and support services. Given that some community services may not be immediately available, a cadre of billable providers has been developed by McFarland to be available for the needs of the Wellness disparate clients that come into care. Examples are a a psychiatrist, nutritionist, and home health care nurse.
Similarly, there are necessary services that fall under the social determinants of health such as homelessness, food insecurity, illiteracy, unemployment, debt, safety, social integration, and transportation. Wellness staff are resourceful in working with the existing network of services in the MDV to address client human and social needs.
The Wellness staff are very conscious of deploying interventions that are cost effective and measurable. As important to the program’s demonstrated success is the staff’s understanding of the relationship with the client as essential to achieving success. Clients have “will” and an emotional history that can undermine or enhance the achievement of outcomes. Listening to understand and coaching to develop self-direction and action are key.