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Care Coordination Chronicles: The Healthcare Marathon

Because if care coordination feels difficult for us as we assist and accompany, we know it must be extremely challenging for the people we work with.


Over the past week, we had something of a care coordination marathon trying to link a patient to appropriate care. This patient needs ongoing care to best manage the traumatic brain injury and musculoskeletal complications developed after he was hit by a car riding his bicycle. After seeing the patient for an appointment, Dr. M referred him for an x-ray and I made the phone call for him to get scheduled and faxed over all pertinent information. However, the office said they didn't have it on the day of his appointment so I had to fax it all over again and Dr. M had to call in and give the order verbally as well. In the meantime, the patient waited 2+ hours to get his x-rays done.


This rhythm of following all the steps and then having to repeat them is a familiar routine even after just 6 months of working with MHI. Even if an individual instance is not too burdensome on time and energy, they add up quickly. The strain on a person navigating the healthcare system and experiencing complex, co-occuring conditions only intensifies.


That same day, the patient texted me about other health concerns so I made calls to see about scheduling him an appointment at a local clinic. On the first attempt, I was put on hold that ended abruptly with a dial tone. The second time, I was able to get through to a person and make an orthopedic appointment, but nothing for the more urgent gastrointestinal issues. Once I was able to get the extension of a person who works at the clinic, I connected them to the patient so the two of them could work together directly. In the next few days, I will follow up with the patient to learn about how he’s doing and his progress.


These hold-ups and hiccups in accessing healthcare do not reflect on the clinics themselves, but rather on the underfunded and overburdened medical system in the United States. We can’t fix these issues at MHI, but we can and do accompany the patient through it and provide information that empowers people to continue and get their needs met. And maybe it’s the clear information and prompt response that led the patient described above to tell me I was “a breath of fresh air into old lungs.”


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