[Music]
Anncr: Welcome to this audiocast produced by
the Minnesota Department of Health,
Health Care Homes program.
Carol: Hello this is Carol Bauer from the Minnesota
Health Care Homes program and we are here
today talking with Becky Engdahl from the
Mayo Clinic in Rochester Minnesota.
Good morning Becky. Becky: Good morning Carol.
Carol: Well I'm so glad you could be with us
today and we're here today to talk about
care coordination. So let's start by
talking a little bit about your
background and how you came to be a
Care Coordinator.
Becky: Well my Nursing journey started in
critical care. I had a summer internship
in a med-surg transplant ICU
that led to a full-time position upon graduation
with my Registered Nurse.
And I spent 10 years there, and even from the
start of my nursing career, I really
valued the power of nursing and
connecting with patients and families to
improve overall health outcomes.
I have the opportunity to have a temporary
outpatient assignment in primary care.
I spent five years in telephone triage and
primary care team nursing, and after that time
I had an opportunity to go into my current role
which is adult care coordination in primary care.
Carol: So it sounds like
that patient connection,
direct patient connection is
really important to you. So, let's talk
a little bit now, about your clinic.
Tell me about the people
you see in your practice and in your community.
What does that look like?
Becky: My role in my area in Mayo Clinic is
I work at Mayo Family Clinic in Kasson, Minnesota.
This is the home of
Family Medicine Residency Program for
Mayo Clinic. It's a growing rural community of
about 50, sorry 6,300 people, 13 miles West
of Rochester. And we support a population
about 13,000 patients, from birth to grave.
Carol: I think that that might be a surprise
to some people, that Mayo has a presence
in rural Minnesota, but it's true.
So how are you enrolling your patients,
identifying and enrolling your patients
in Care Coordination?
Becky: Well, my role in Care Coordination
has been adult chronic disease for the past five years.
It is undergoing some changes. At this time,
we're going to start studying the effectiveness
of Care Coordination roles
in the reduction of hospital readmissions
for patients with multiple chronic conditions.
And being, that it's a research study
at that time our population
will be determined by a registry based only.
Carol: Registries are one of the challenges
but you've had a lot of challenges
along the way to building
a robust Care Coordination story.
Carol: So what do you remember as being,
you know, especially challenging for your team and
your patients, and what did you do to
work through some of those challenges?
Becky: When patients have limited access to
their primary needs. It's difficult to address
or promote self management of
their chronic conditions. I continue to feel blessed
to have numerous resources here at Mayo Clinic,
through Community Health Workers,
both Clinic and Community
or County Social Services, and there are
several non-for-profit organizations out
in the community that do partner with
patients to overcome such barriers to health.
Carol: That's really great, that you have
all that in motion. Can you talk a little bit more
about some of your community partnerships?
I think people would find that interesting.
Becky: Mayo Clinic has a
community partnership with a nonprofit organization
in Rochester, called IMAA,
to have Community Health Workers out
here in primary care. They have been an
incredible valuable resource we had
in the last couple years, to connect patients
with these Community Health Workers,
that are able to meet with them one-on-one
and kind of help guide them
to what community resources are available.
Carol: Great that you've been able to
get to that level, where you're working
with your community. If you talk a little
bit about how Care Coordination has
changed your practice and what are you
learning as you continue to evolve?
Becky: Well Motivational Interviewing has been
an effective tool, that I learned through my role
in Care Coordination and this
has changed how I communicate,
how I promote discussions on behavioral
change in my professional, and in my
non-professional life. Communication with
Motivational Interviewing, can help
uncover their story, and help provider
and patient discover that, the
inner motivation for behavioral change.
And so, throughout my time in Care Coordination,
I continue to learn and improve
my technique with this skill.
Carol: Looking back, what advice would you offer
to clinics that are early in their
Care Coordination journey? What do you know
now, that you wish you'd known when you started?
Becky: So my advice to those early in
their Care Coordination journey: network,
find your team, don't be afraid to reach out
to specialists to community activists,
anybody who can help find the answers.
For instance, when I was very new
in the Care Coordination role, I was paired
with a complex COPD patient that
led me to a friendship and a partnership
with a COPD Inpatient Respiratory Therapist.
And five years later, she is still
one of my go-to people, when I'm struggling
on what to do with patients
with complex COPD that we're working to
improve their management with.
Carol: So well, that's all I've got for you today Becky.
But thank you so much, for sharing
your experiences with us and your wisdom.
This is our very first podcast,
Health Care Homes stakeholders and we are looking
forward to bringing you more in the future.
So this is Carol Bauer, from
Health Care Homes, signing off. Thank you Becky.
Anncr: Please visit the Minnesota Health Care Homes
website for more resources to
help you deliver, a patient-centered
team-based care. Thanks for listening.
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