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Coordinated Care Transforms Lives

 |  For Patients, For Providers
Scott Elliott with Dr. Nathan Tholle
Scott Elliott (L) with Dr. Nathan Tholl

“Anyone can transform healthcare, but it takes special people to transform lives. That’s what we do. We transform lives.”

Scott Elliott
Arizona Care Network (ACN) Social Worker

Elliott sees how coordinated care can impact patients’ lives after just one year of working as a Social Worker embedded in one of ACN’s Comprehensive Care Clinics.

What ACN’s Care Coordination Team Does in Comprehensive Care Clinics:

  • Serves Medicaid members managing both medical and behavioral health challenges
  • Works with physicians to provide all patients with the care they need
  • Collaborates to help patients with medical and socio-economic challenges, and potentially behavioral health concerns
    • Example: If a patient with diabetes needs to maintain a healthy diet but they do not have the money or resources to do so, our team helps the patient find community resources and builds rapport with that patient to help them achieve their best health

“No matter how busy he gets, Scott is always available to discuss existing patients and see new patients. He has a positive attitude and patients are quite receptive to meeting with him,” Dr. Nathan Tholl said.

ACN’s Care Coordination team values the overall health and well-being of every single patient. Social workers often play a significant role in identifying psychosocial stressors such as food, shelter and transportation. Elliott recently transformed the lives of two patients by doing just that.

From Isolating Himself to Communicating His Needs

Identifying the Problem:

  • One patient Elliott served was socially isolated, with no local family friends after his only caretaker had passed away a few months back
    • According to the Centers for Disease Control, 13.5 percent of patients who require home care experience major depression.

“Scott has never given up on this patient. I can’t count the times he has been out to this patient’s home and has been in constant communication regarding the patient’s concerns and needs,” Dr. Tholl said.

The Solution:

  • Elliott visited the patient’s home several times and connected him to necessary resources
  • Elliott set this patient up with Meals on Wheels, an organization that delivers breakfast and lunch to low income patients for free

“I strategically use this service with patients who are home bound. The delivery person shows up at the person’s home, which serves as another welfare check,” Elliott said.

The Outcome:

  • The patient began to engage with providers
  • Takes more interest in his care and will now even call providers to arrange services he needs

From Lacking Resources to Getting the Care He Needs

Identifying the Problem:

  • A second patient Elliott recently met is an older adult who was living outside in the Arizona heat
  • The patient has a colostomy bag that needs to be maintained, and due to his living situation, he was having hygiene and health issues

The Solution:

  • Elliott met with this patient and had a place for him to live within two hours
  • A Patient Navigator followed up with the patient to ensure everything went according to plan and that he was getting the medical supplies he needed
    • Patient Navigators help patients achieve their best health by assisting with finding a provider, identifying gaps in care, finding resources or resolving road blocks.

“The Patient Navigator immediately jumped in and we were able to change his life in a matter of hours,” Elliott said.

Patient Navigators are ACN’s healthcare insiders — experts at problem-solving to ensure every patient has the care and resources they need.

The Outcome:

  • Getting this patient into a safe, climate-controlled dwelling allowed him to properly care for his colostomy bag and get needed medical supplies delivered to his new home address

The Care Coordination team is committed to identifying and treating the problem, not just the symptoms.

What Every Patient Needs to Know

Care Coordination is available to all patients whose Primary Care Provider is part of Arizona Care Network. Our team works with your doctor to give you the extra support that makes it easier for you to get healthier and stay healthier.

“The first thing we provide is support. You know that someone is in your corner and someone cares,” Elliott said, “After that, we have clinical knowledge and connections to resources, so we can ensure our patients are receiving the care and the resources they want and need. We take a patient-centered approach to it, allowing patients to steer their care. They tell us what they want and what they need, and we help them with it.”

There is no charge to the patient for care coordination services. For more information or to see if you are eligible, contact the ACN concierge line at 602.406.7226.

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