Every person’s health needs are unique and navigating the healthcare system can be overwhelming. Patients might struggle to get the care and services they need to recover from an illness, manage a chronic disease, or find that returning home to self-care after a hospital stay is overwhelming. Care managers like Vivian Roderick, BSN, RN, ACM are highly skilled and can help coordinate all aspects of your care. We sat down with Vivian to ask more about her role and how care managers help coordinate all aspects of care for Aspire Health Medicare Advantage plan members here in Monterey County.
Tell us about your background and how and why you decided to get into care management.
I started my nursing career taking care of premature babies in an intensive care nursery. After six years, I made the change to adult medicine and worked in hospitals and home health settings before becoming a director of a care management program for a large clinic providing chronic care management to patients experiencing diabetes, hypertension, heart disease, congestive heart failure, chronic lung disease, as well as to those recovering from heart attack and stroke.
I continued on in care management because it was extremely rewarding to be able to guide and support people struggling to manage chronic illness whether at home or transitioning from a hospital stay to home with a new illness and needing education on self-care management. Many patients find themselves easily confused by all the instructions they are given from their physicians. They need support to review their disease or illness, review the reason for and the proper way to take their medications, help make appointments and provide education that ultimately places them on the path to recovery. Our goal as care managers is to guide patients through the unknown to achieve optimal health through education and behavioral modifications in lifestyle which ultimately improves outcomes.
Talk about your role as a care manager. What kind of support do you offer to those managing chronic conditions?
As one of my patients recently said, “My care manager is a light in the darkness.” Those who have experienced illness know that navigating through the healthcare system is difficult. Care managers remove barriers and confusion, providing care coordination with physicians, scheduling appointments, ensuring medications are taken correctly, educating patients and caregivers on disease management and making ongoing calls to ensure to address new and or worsening symptoms. We do this at the initial interview with the patient and we course correct at every follow up visit as needed. We intervene when patients are experiencing new or worsening symptoms, linking the patients to the appropriate physician and other essential providers such as health coaches. As an example, when a diabetic is struggling to control blood sugar and all appropriate medications are being taken as directed, a referral to a health coach may be appropriate to enhance education on nutrition and healthy lifestyle changes. When there are financial or lack of essential resources at home, a referral to one of our social workers can be made for connection to community resources.
How do care managers help Aspire Health Plan Medicare Advantage members?
At Aspire Health we reach out to all our members who are hospitalized or who visit the emergency department (ED) for care and offer our assistance through their transition from hospital care to home. We also identify our at-risk population within our membership and reach out to these members to offer support in managing their complex illness. We provide early identification of problems that might be contributing to poor health, abnormal labs, elevations in blood pressure, or blood sugars and provide education on prevention of disease and assistance in managing symptoms. When needed, we help patients with scheduling, transportation and provide additional resources to ensure they get the care they need.
How do care managers work with other members of the Enhanced Care Team including engagement specialists, health coaches and social workers?
Our enhanced care team consists of health coaches, social workers, and engagement specialists. We refer our patients as needed to the appropriate team member to help provide additional education, guidance or support for our member’s unique needs. Our goal is to provide our members with the help they need to experience optimal outcomes.
Over the years, Vivian recalls so many wonderful experiences with patients. “Some of them, I have worked with for so long that they have become like family to me,” she says. “I enjoy solving difficult problems for our members and guiding them to make changes which improve not only their health but their psychosocial well-being. I believe my job is not just clinical in nature. It is necessary to provide emotional support to caregivers and patients experiencing difficulty managing a patient with severe and chronic illness.”
“There have been many patients, with problems that were not just related to their disease, but also related to the home environment,” she continues. “We look at the whole picture as care managers and do our best to resolve those things that are contributing to poor health. This may include making significant changes to their living environment.” She shared a story about one such patient living with chronic disease and experiencing many hospitalizations at a risk for many more. His needs included a comprehensive care plan which involved his family making changes to his living situation, diet and medication management regime. Once these changes were made, the patient’s health began to improve and ultimately decreased his episodes of illness and hospitalizations which positively impacted the quality of his life.
“Comprehensive care management is a team effort,” says Vivian. “The patient, their caregivers, the physician and the care manager all must be involved and work together as a team to help patients gain control of their health care needs. The care manager is central to this work, and ensuring our patient receive the best care is our goal at Aspire.”
As an Aspire Health Medicare Advantage Plan member, you have no-cost access to an enhanced care team, including care managers. Request more information by calling (831) 644-7490.