Much of what affects the health and healthcare of Anderson Free Clinic patients happens outside the clinic. Because of that, Anderson Free Clinic now has a new Care Coordinator, a staff RN who is working with our most vulnerable patients to improve their health outcomes by looking at factors beyond the clinical setting. Those might include education, income, housing, smoking, jobs, transportation, and healthcare literacy.
The Care Coordinator works with patients to address these complex health and social issues by offering ongoing support. AFC patients identified as having missed multiple appointments, non-compliant with their health plan, and using the emergency department frequently for primary care services are selected and invited to participate.
Care Coordination helps patients manage the medical, dental, and pharmacy services already offered to them at the Free Clinic. In addition, health education, self-care skills training, counseling, and medication management tools are provided to patients and family members in need of additional resources as well as facilitating access to other existing community resources here in Anderson for the purpose of improving quality of life and reducing additional external stressors.
Using a care guide created together with the patient, the Care Coordinator monitors the patient’s progress regularly through phone calls, texting, clinic visits, and support which helps guide their self-care practices.
The success of the program will be measured by a decrease in unnecessary visits by program participants to the ER, self-management of conditions like diabetes improving, and patients keeping appointments at the Free Clinic. Care coordination offers continuity and an ongoing relationship with chronically-ill adults while offering encouragement and education to empower the patient for long term control of their health.
The new Care Coordination program is made possible by a one year grant from the CVS Health Foundation, in partnership with the National Association of Free & Charitable Clinics