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How a phone call can help a community at risk

Body, Physicians

Jill Borth is on a mission. As an RN manager for care management at Adventist Health Lodi Memorial, Jill and her team transform the way the at-risk senior population receives primary care. She not only changes lives, but cuts costs—for hospitals and the community.

“I was born with a passion to promote health,” Jill says. She’s been applying that passion for the past 32 years in various nursing settings, and at Adventist Health Lodi Memorial for 27. From ambulatory care to admitting and recovery rooms, Jill has seen it all—and one thing has become clear: Many patients come into the ER with preventable conditions. Uncertain whether it is due to a lack of education or information, Jill feels called to do something more to help these members of the community before they need emergency care.

After taking a health coaching course, Jill realized there was an opportunity to expand her role to include population health in the Lodi community. She decided to spearhead a chronic care management program to help seniors with chronic conditions (such as high blood pressure and high cholesterol) improve their lifestyles and health. The goal of this initiative is to do more than just improve health conditions, but also reduce the amount of money spent on ER visits.

How does it work?

Patients with two or more chronic conditions are referred to the chronic care management program by their primary care physician. These are patients whose health is trending down, but are motivated to change. They have at least two chronic conditions such as lung disease, heart disease, chronic pain and depression, and most are prediabetic or have Type 2 diabetes. They need care coordination, resources and education. Jill establishes those needs and sets goals with her patients to improve their health and prevent trips to the ER.

Jill’s approach is simple: All it takes is a phone call.

Using a “stoplight zones” approach to these calls, Jill determines what a patient’s needs are and if he or she should seek medical care. Each “light” represents a different set of symptoms. A green zone means a patient’s breathing and energy are normal. A yellow zone signals a patient may be feeling a little fatigued. A red zone warns that a patient is sick enough to require an ER visit. “I tell patients to call me when they’re in the yellow zone,” Jill says. Often, she can triage the patients away from the ER because their symptoms aren’t to that level.

With the “call me first” approach, Jill teaches her patients self-management skills and what it takes to stay well. Partnering with them in this way shows the patient they are not alone, and it helps ensure they seek help before their symptoms are in the red zone.

During these calls, Jill schedules appointments and follow-up tests to make sure patients stay on track with their health. She’ll even arrange transportation for those who need help getting to their appointments.

Jill uses a motivational interviewing technique to set realistic goals, like trying to help a patient lose weight so they don’t have to take certain medications anymore. “We celebrate successes and talk about challenges and roadblocks.” Jill says. “There’s no guilt or shaming if they didn’t reach their goal. We’ll find a different avenue to get them there.”

Simple tactics like these could be the answer for improving the health of an entire population, especially when it comes to lifestyle diseases such as Type 2 diabetes. A common thread is communication—and this takes time. Jill says it takes a few months to find out where patients are on their journey.

“We’re looking at this in Lodi as a way to transform primary care,” Jill says. “If I can take some of the load off primary providers and help improve the quality of a patient’s life, I’ve reached my goal.”

And it’s working. Jill’s calls often provide a sense of relief and gratitude. One woman—who also suffered from clinical depression—started crying when Jill called her. “I have been suffering for 20 years while trying to figure my healthcare out on my own,” she said. “It is so hard—but knowing I have someone I can call to help me navigate this puts a smile on my face. I haven’t smiled this much in a long time.”