Extra patient support is at your fingertips.
As a clinically integrated network, Arizona Care Network has a team of social workers who collaborate daily with network providers to assist patients needing additional support and resources to achieve better health.
These social workers are part of ACN’s Care Coordination team, a benefit of ACN membership available at no cost to in-network providers and their patients.
A typical day often includes:
• Connecting with providers (and patients) over the phone or in person
• Providing answers and access to both provider and patient resources
• Advocating and educating a patient about their medication(s)
• Coordinating and even attending healthcare appointments with patients, if requested
“We try to be investigators or detectives to help bridge provider care with patient needs,” said social worker Christine Abanilla, who specializes in Medicaid patients. “We do our best to find out the ‘why?'”
Understanding the “why” can be life-changing for a patient, greatly improving healthcare outcomes while helping the provider support a lower cost of care. It’s why a social worker’s typical day often means driving around the Valley to foster a relationship with at-risk and vulnerable patients, or to meet with providers.
ACN Care Coordination Manager Sheila Jackson recalled two social workers who recently met with a provider in Phoenix about care for a patient who was homeless, then walked from the provider’s office to meet the patient under an overpass.
Within two days, the social workers helped the patient find shelter and complete the qualification process toward receiving assisted living resources.
“Building a connection with patients is huge because they’re often more open and honest with us,” Jackson said. “A lot of times people don’t know what to do or what’s next until they get home, or find out how much a prescription medication costs until they get it.
“We can help clear roadblocks when a patient reaches one, or before we even get there.”
If a behavioral health diagnosis or socio-economic challenges add complexity to a patient’s care, providers can call or email the Care Coordination team to meet with one of their patients, especially if a provider feels social determinants of health are contributing to a patient’s repeated visits to an emergency room or hospital admission.
ACN social worker Scott Elliott recently drew rave reviews from Dr. Nathan Tholl for Elliott’s work with several of Dr. Tholl’s patients within Dignity Health, as well as its Peppertree Family Practice Center, one of ACN’s Comprehensive Care Clinics that serves a large number of Medicaid patients. Elliott often sees patients who need extra attention and support beyond the time afforded during a typical appointment, due to physical, mental, behavioral and/or socio-economic challenges.
“They go above and beyond,” Dr. Tholl said of social workers. “They get a glimpse into [patients’] home or daily life situations that we as providers don’t necessarily get to see.”
Jackson estimates that her social workers assist 10-20 at-risk or vulnerable patients on a given day. This includes phone calls, provider visits and frequent in-home or on-location visits.
Whether it’s transportation, understanding medications or supporting patients in need of housing, food and other daily necessities, ACN social workers make repeated visits with providers and patients to listen, learn and act.
“It’s always beneficial, even if it’s small,” said ACN social worker Leticia Gutierrez. “It doesn’t need to be a major curveball. We can take the time to listen, go to their home, wherever, to build a relationship.”
