Complex Care Management – A New Way to Enhance Healthy Outcomes

Rachel Hernandez-ChavezThe JHMB recognizes that primary care physicians are a crucial resource for keeping members healthy and keeping healthcare costs affordable. Given a shortage of primary care physicians both nationwide and in Fresno, primary care physicians are turning to “complex care managers” inside their offices to provide extra levels of care to those patients who need it. HealthConnect recently sat down with Rachel Hernandez-Chavez of Community Medical Providers to learn more about complex care managers and how their efforts impact the health and well-being of Fresno Unified employees.

HealthConnect: Rachel, what does your average day look like?

Rachel: An average day starts by checking emails and reviewing work from the day before. A good portion of my morning goes to reviewing the daily hospital discharge reports. When appropriate, I do a follow-up call and review medication lists and discharge instructions with the patient or caretaker and make a follow up appointment with the primary care physician. My daily schedule varies and can include diabetes support meetings and/or classes and face to face contact with patients who may benefit from additional education and support. These face to face contacts are done in the primary care physician’s office after a scheduled office visit.

HealthConnect: How do your efforts impact Fresno Unified employees?

Rachel: I call members on the phone to reengage patients with their health care. It has been a key opportunity to provide education and support for patients who are dealing with multiple health problems. The telephonic outreach has also proven to be a great way to help resolve problems a patient may have with their medications or the management of a chronic health issue which may be handled simply by re-educating the patient and/or scheduling a follow up visit with their doctor. This is the team approach to improving health that a patient centered medical home strives to do.

JHMB continues to work to ensure that its members find local resources like Rachel that can help them maintain good care and improve their health.

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