Dr. Michael Anderson (Host): Hello, everyone, and welcome to this episode of the FortCast, the official podcast of Fort HealthCare. I am your host, Dr. Michael Anderson, ENT doc and President and CEO of Fort HealthCare. I'm very excited today to have two special guests with me today. I have two wonderful nurses with me, Erin Sterwald and Sam Fuller. And they run and are very integral in our Comprehensive Care Management Program. So, we are going to talk about that today. I know I am going to learn a lot. I think this is an initiative, a program that we don't highlight nearly as much as we should. So, I'm very interested in learning more today with both you, Erin, and you, Sam.

So, let's just start with some introductions. So, our listeners know I've been with Fort HealthCare for roughly 20 years, a little over 20 years. But Erin, let's just start with you. How long have you been with Fort HealthCare? Tell us a little bit about yourself.

Erin Sterwald: Sure. So, I started with Fort HealthCare in 2019. I was hired to initiate and begin our Comprehensive Care Management Program. Prior to that, I was at a different healthcare system, but I've been a nurse for, oh gosh, almost 20 years now.

Host: Well, that's fantastic. And it was truly our benefit in 2019 when you came over for us. So, thank you for being part of Fort HealthCare. And Sam, how about you?

Sam Fuller: I have been a nurse for about 10 years now, I think. Yeah, a little over 10 years. My background was in clinic nursing originally, that was with Fort HealthCare. Then, I left for a little bit to do case management, and came back with Erin to do Chronic Care Management here at Fort HealthCare again, and I've been back for about three years.

Host: Well, that's wonderful. Thank you for coming back, and we're happy to have you. And, you know, the field of Medicine never ceases to amaze me in that we love our acronyms. So, your program is often referred to the CCM Program, which I learned today is the Comprehensive Care Management Program. So, just tell our listeners, Erin, we can start with you, what exactly is a Comprehensive Care Management Program? What does it mean?

Erin Sterwald: Sure, sure. Sometimes this program is recognized as Chronic Care Management. And, of course, then we kind of shortened that up to CCM. We looked at this program and we said, you know, we're really looking at patients as a whole. And so, we kind of switched up the name a little bit to Comprehensive Care Management. And again, we shorten it to CCM. Our Comprehensive Care Management Program is designed to support patients that are living with multiple chronic illnesses. As RN case managers, we really work closely with patients to carry out interventions that are aimed at improving patients' quality of life. We help manage the symptoms that they may be dealing with. And then, we help prevent complications associated with their health.

Each patient, we develop a personalized care plan with, and that really allows us to to dive deeper into what outside factors may be contributing to their health. So, for example, is their medication too expensive? Do they have the appropriate resources in the home to help with activities such as bathing, preparing meals, going grocery shopping? Can they get around the house safely? Do they have rides to their medical appointments? And really looking at the social support that they may have. And then, what we can do is we can identify their needs and help connect patients to those community resources that we have and that are really readily available for them.

We find that patients that have multiple chronic illnesses really can be overwhelmed at times. It's an overwhelming feeling to have and try to manage multiple chronic illnesses. One example that we see frequently within our healthcare system is we see patients that come in for their office visit with their primary care provider. At this appointment, the provider may say to the patient, just for an example, "Their blood pressure is high. They need to lose some weight." Now, we have to refer you to an outside specialist for a cardiac referral or some cardiology issues they may be having. The provider also at this appointment recommends, "Gosh, we've got to start you on some new medications for your blood pressure. I want you to start an exercise program. I want you to change your diet. And then, I'm going to see you back in six months to see how things are going." And so, the patient leaves this appointment feeling overwhelmed and like they have a lot on their plate to do. And sometimes, what they do is they go home and they're so overwhelmed that they don't necessarily do anything.

So, that's where really CCM, our program, can make a difference. So, we can help guide patients with education. We provide them ways to help self-manage their illnesses at home. We do frequent check-ins to monitor how their health status is with the implementations that they've been doing. When the patient then returns in six months for a followup, progress has been made. And then, the provider and the patient can really work then towards the next goals that they're trying to achieve.

Host: Boy, Erin, that was a ton of information, and I heard a lot in there. I want to highlight a couple of things that you mentioned. First of all, it truly is a comprehensive program. I heard a lot sprinkled in with social determinants of health. These are the Achilles heel of health outcomes, right? Your food, how good is your food security, your transportation. I heard those words really get highlighted in what you just told us. And then, just the overwhelming nature that some patients feel when they have multiple chronic illnesses. And, you know, it's really hard to get a sense of what you're supposed to do in a 30, maybe 45-minute visit with a physician or a provider, then they leave the office, I guarantee you, so overwhelmed that they don't even know where to start. And so, that's when your program really is a huge asset to these patients. And bravo, hats off. And then, I have a followup question. Sam, who typically qualifies for the CCM Program, the Comprehensive Care Management Program?

Sam Fuller: Any patient with a Fort HealthCare primary care provider who has been diagnosed with one or more chronic illnesses is eligible to enroll in our program. A chronic condition is an illness that is expected to last for at least 12 months and cause a decline in the patient's health. Some examples of chronic conditions might include hypertension, diabetes, depression, heart failure, kidney disease, and even COPD. So, the list is quite extensive and does go on and on. Lots to choose from there.

Host: And unfortunately, a lot of those are really common. So, just a followup question on that, in addition to the qualification, does the physician put an order in or what's the trigger to get them into the program?

Sam Fuller: The primary care provider would send an order or a message to our department. And then, we would reach out to the patient and get them enrolled in the program.

Host: That is fantastic. So Erin, getting back to you, a patient gets enrolled in the program. And I'm sure you work so closely with these patients. What are some of the benefits to the patients that you see in the CCM Program?

Erin Sterwald: Sure. So, our patients that are enrolled in our CCM Program, we really see several benefits that they experience while they're enrolled. Some of the key advantages that we see is definitely an improved quality of life. So, we really aim to enhance the quality of life for these individuals that are managing these multiple chronic conditions. With our support from CCM, patients are more likely to achieve their health goals. And this really does lead to a reduced amount of stress. We see that the patients have a stronger connection to their healthcare team. Regular interactions and personalized attention really help patients stay connected and engaged in their health care. And this really does lead to patients taking that proactive approach to health. So, we find that patients are really wanting to be on top of things, getting their preventative care services taken care of. And, again, another benefit we see is then that leads to that reduced hospitalization and ED visit, or amount of emergency department visits that they have.

When CCM is done effectively, we really can reduce the amount of time that a patient may be in the hospital for, complications, and unnecessary emergency room visits. And by managing these chronic conditions more effectively, like you were saying, Dr. Anderson, before, it really does lead to patients experiencing better outcomes.

Host: Yeah, absolutely. And to just follow up on a couple things that you mentioned there, it's care beyond the walls of your healthcare system. And that is so important because if you have programs like the Comprehensive Care Program, then you can extend that care beyond the walls, get that patient contact. And really, I loved when you commented on the downstream benefits of reduction in emergency room visits, less or shorter hospital stays, that is a huge benefit to everybody. Especially in healthcare today, we really struggle with access issues, meaning we really struggle to get everybody seen. So, anything that we can do as a system with initiatives such as the CCM program to really reduce ER visits and reduce hospitalization is going to benefit everybody, everybody involved.

Erin Sterwald: Exactly. And we see too, you know, another part of our responsibility is to really help coordinate that care. We see a lot of patients that have multiple specialists that are managing their care. And we really make that connection between all their providers so that they can have that continuity of care, and everybody's on the same page with what's going on. And again, that really does help, again, reduce the amount of time that patients may be coming into clinic or, you know, again, like we were saying with the hospitalizations and reduced ED visits.

Host: Yeah, no, that's well said. And I'd like to expand on that a little bit. So, Sam, could you tell us a little bit specifically what is the-- because I notice I'm talking to a couple nurses here today, and what is the role of the RN in the CCM program?

Sam Fuller: our role as Comprehensive Care Management nurses is to work alongside with the patients and their caregivers. We try to provide additional assistance to help them manage their chronic conditions. We work, like I said, alongside with them to coordinate care with their primary care providers along with the specialists that they might see on a routine basis, advocating for patients along with educating them regarding their illnesses and collaborating with the entire care team like Erin mentioned earlier. Providing additional assistance when a change in their treatment might be needed is another element that we can work with patients on. The CCM team is available for patients to help as little or as much as they would prefer.

So, each patient's care plan is a little different. Like Erin mentioned earlier, we tend to interact with them over the telephone, and we kind of call ourselves the visit in between the visits, so trying to cut down on the amount of in-person clinic visits that a patient might need. So, we tend to follow up with them while they're at home via telephone in that way, so that they can stay on track with what they need to do for their upcoming visits.

Host: Yeah. I mean, it sounds like your role is crucial in the care of these patients. I mean, they have so many medical conditions. I imagine their head is swirling at times. And to have you and your team reaching out to these patients and serving as a resource is invaluable to their care. I can just imagine how much better the patient feels knowing that you're part of their care and part of their care team. So expanding on that, what would be the next steps for a patient if they were interested in learning more about the CCM program?

Erin Sterwald: Again, we love our job. So, we love taking on patients. Patients that are interested can have that conversation with their primary care provider. And what would happen then, kind of like we talked in the beginning, the patient expresses interest and the provider agrees, they have that conversation and then the provider can put the referral in. That comes to us and then we would be giving the patient a call within the next couple days to talk about what the program is and kind of go from there ,setting up their care plan and what to expect. It's really neat.

We, on the forthealthcare.com, do have a section in there under Services, and it's the Comprehensive Care Management Service that patients can go in and read a little bit more about what the program is, again, what the benefits are and what to expect during their enrollment. So, it's kind of a neat site if they go on the forthealthcare.com. And then, underneath Comprehensive Care Management, they can read a little bit more about it.

Host: Outstanding. Really, if a patient is listening to this podcast, either you or a loved one or a close friend has multiple chronic illnesses, make sure that the patient that's being seen by their physician or provider knows about the CCM Program, because that's really the trigger, is to get that physician provider order to trigger the CCM program. Well, I'll tell you what, I learned a ton about the CCM program today. Erin and Sam, thank you so much for being on this episode of the FortCast. Thank you.

Erin Sterwald: Thanks for having us.

Host: And if you found episode of the FortCast helpful, please go to our website to check out our full library of our FortCast episodes and please share it on your social media channels. For now, this is Michael Anderson signing off. Thank you for listening. And thanks again to Erin and Sam for being part of today's episode. Thank you and have a great day.