How an FQHC Used Caseworkers for Chronic Disease Management

How an FQHC Used Caseworkers for Chronic Disease Management

In the wake of workforce challenges, Bluestem Health outsourced caseworkers who have been instrumental in supporting the FQHC’s chronic disease management efforts. The Nebraska-based Bluestem Health knew whole-person care that accounts for behavioral health and SDOH would be the key to complex chronic disease management, but in the throes of a nationwide workforce shortage, the federally qualified health center (FQHC) wasn’t left with many options. After nearly five years of focusing on chronic disease management, leaders at Bluestem had determined that traditional provider-led health coaching couldn’t move the needle alone. The organization, which participates in the Centers for Medicare & Medicaid Services (CMS) Chronic Care Model (CCM), first deployed behavioral health strategies to uncover the barriers to patient engagement in care management.

“We know in our practice that if patients are coming to their appointment, they don't want to be non-compliant,” Brad Meyer, Bluestem Health’s CEO, told PatientEngagementHIT in an interview. “We've always known that patients don't ask their doctors questions, because they're afraid to look dumb or look a certain way during the visit,” Meyer continued. “And so they're able to talk to these behavioral health therapists a little bit more openly, and then the behavioral health therapist can then either relay that information to the provider or work with our certified diabetic educators or our chronic disease nurses to put more emphasis and focus on that patient.”

But as those behavioral therapists began to uncover some of the downstream factors keeping patients from optimal chronic disease management, it became clear Bluestem couldn’t go it alone. Many of the patients enrolled at the FQHC experience multiple social determinants of health, as well as other patient health literacy barriers that keep them from achieving wellness.


Next Article

  • How an FQHC Used Caseworkers for Chronic Disease Management

    Why Independent Practices Need EHRs to Boost Productivity

    As private practices everywhere struggle to maintain their independence, they face changing reimbursements, demanding regulatory requirements, and ever-increasing costs. Implementing an electronic …

    Posted Jun 15, 2022

Did you find this useful?

Medigy Innovation Network

Connecting innovation decision makers to authoritative information, institutions, people and insights.

Medigy Logo

The latest News, Insights & Events

Medigy accurately delivers healthcare and technology information, news and insight from around the world.

The best products, services & solutions

Medigy surfaces the world's best crowdsourced health tech offerings with social interactions and peer reviews.


© 2024 Netspective Media LLC. All Rights Reserved.

Built on Mar 28, 2024 at 3:00am