Ann didn’t know it, but she was in for the fight of her life.
After going to bed one evening with a headache, Ann awoke the next morning unable to speak. Aware that something was seriously wrong, her husband called an ambulance to rush Ann to the hospital.
By the time the ambulance arrived, Ann’s condition had deteriorated further; once the paramedics arrived, they had to stabilize her before they could even bring her to the emergency room.
Once there, Ann was diagnosed with bacterial meningitis, a serious condition that put her in a coma for 17 days. Twice during her treatment, she died and was revived by her medical team. Care providers diverted her blood flow to her vital organs just to keep her alive, but this meant circulation was decreased to other areas of her body. Ann finally woke up to the grim news that both her legs would have to be amputated below the knee, along with her right thumb.
After a long and difficult recovery, Ann was able to return home, only to face new challenges and ongoing health issues. She left her rehabilitation facility with no plan for handling at home care. To make matters worse, she struggled to get help from state and county social services programs.
A Health Care Home
Then Ann found University of Minnesota Physicians Phalen Village Family Medicine Clinic. Ann chose the clinic for follow-up care because it’s close to her home, but over time she learned that the clinic offered her much more than convenience.
Phalen Village is a certified Health Care Home. Under its multi-disciplinary approach, primary care providers, families and patients work together to improve health outcomes. The Health Care Home program assists patients in a variety of ways, from arranging for home nursing care to helping them find financial aid. A Health Care Home can be particularly beneficial for patients struggling with multiple health issues or disabilities, but the overall approach is applicable to all patients, including those with routine or less severe health care needs.
At the clinic, Ann works with Dr. Angela Smithson and Jody Rothers, a care coordinator, to manage all aspects of her health care. Jody is there when she comes in for an appointment to help ensure that all of her questions are answered. She also helps arrange any referrals when Ann needs to see specialists, and follows up to ensure their care is coordinated with Dr. Smithson’s. She even works with county employees to help Ann get needed assistance.
“Jody keeps track of my issues and what’s happening with my care,” Ann said. The Phalen Village clinic, she noted, is not big and hard to navigate, like some social services systems. She also appreciates the community feeling at Phalen – which is a valued part of her neighborhood.
A Novel Approach
The Health Care Home is a novel approach to patient care management, according to Dr. Smithson. Using the method, a clinic team can easily track a patient’s personal goals and connect the patient with other needed services, whether it’s scheduling a colonoscopy or helping them access community services. Team members also assess a patient’s support system, which can be vital for those with chronic conditions or disabilities. The care coordinator is crucial to this process.
“Sometimes a patient feels more comfortable bringing up an issue with the care coordinator instead of with a doctor,” Dr. Smithson said. “The patient usually develops a very close relationship with the care coordinator.”
When a patient enrolls in Health Care Home, Dr. Smithson likes to get the care coordinator involved at the patient’s first visit so they can immediately start working together to ensure the patient’s needs are met. She describes this approach as “family medicine PLUS” and encourages all patients to consider enrolling in Health Care Home.
Under the Health Care Home system, patients don’t necessarily need to come into the clinic to get help, according to Jody. “I check in with my patients on the phone at least once a month to see how they’re doing and if they need anything,” she said.
Now, every sunrise brings a new day for Ann to pursue her dream of writing short stories and novels. “It’s easy dying,” she says. “It’s hard coming back to life. When you come back the second time, you do what you love to do.”