New Care Program creates Personal Connections with Patients

By IU Health Senior Journalist, T.J. Banes, tfender1@iuhealth.org

On a recent afternoon, Courtney Mills was on the phone booking a ride for a senior patient. The call was just one of many Mills, a nurse navigator, logs in a single day.

She’s part of a care management team that offers special resources to a specific patient population – the elderly, and those with a limited income.

The Connected Care location on East Washington Street opened in April. A second practice is located at IU Health Saxony.

The healthcare sites focus on collaboration that results in the overall best outcomes for Medicare patients.

In addition to a nurse navigator, the East Washington Street location includes: a Nurse Care Manager, Heather Land; Social Worker, Christine Ryan; Physician Assistant, Kristin Willis; and Pharmacist, Kristen Abbott. Dr. Kamal Wagle is also part of the team. He joined IU Health in 2015 with a focus on family and geriatric medicine.

Several connecting points set this practice apart from other offices. Appointment times are longer; patients receive additional education, and are introduced to a wealth of community resources.

Words like, “Concerns,” “Compassion,” and “Communication” are all part of the model.

“We’ve had a lot of patients say, ‘We feel listened to,’ especially with the geriatric population,” said Christine Ryan. Patients are all over the age of 65; most are in their 70s and some are in their 80s and 90s.

“Many times these patients don’t just have one thing going on but several things,” added Ryan. They may come into the office with blood pressure issues and staff members learn there are also issues with diabetes, depression, heart disease, medical compliance – even broken bones.

When the team members began seeing more patients needing canes, walkers, shower chairs, and raised toilet seats, they scoured second-hand stores and built a supply.

“Sometimes they have limited coverage for these things or they don’t understand the process to apply,” said Ryan. The specialized care extends to education about medications, behavioral health, and diet and nutrition.

When a patient needed to puree her food, Heather Land sought out a donated blender.

“This was something that impacted her ability to take her medication,” said Land, who worked with a similar population at IU Health Methodist Hospital for 10 years.

“I feel like I can tangibly help them and I like to troubleshoot, collaborate, and solve problems,” she said.

“There’s a fundamental set of unfairness like if they don’t have Internet they can’t apply for food stamps. They’re left behind. It takes so little to make a phone call,” said Ryan.

In addition to the time spent face-to-face with patients, there’s a lot of follow-up phone calls.

“I have patients who sadly say they look forward to our calls because they have no one to talk to,” said Land. “They need help but they also help us learn through these experiences,” said Mills.

“It’s about listening and understanding and showing empathy, building trust and treating them the way we would want to be treated,” added Ryan.

And one of the greatest rewards for caregivers: “I think we’ve all been hugged at some point,” said Land.