Community is the Best Medicine
St. Joseph Healthcare takes care management beyond the hospital walls
There’s no “one size fits all” approach when it comes to treating patients, and no one knows that better than the Care Management team at St. Joseph’s Healthcare. They always look at the bigger picture when it comes to patient care, which is crucial when working with vulnerable populations such as the homeless, the elderly, people struggling with substance use disorder, victims of human trafficking, and those who suffer from chronic diseases. “We need to be aware of all the resources around that person, and understand what matters most to them, what health and wellness mean to each individual, uniquely,” said Care Management Director Jessica Taylor. Rather than waiting for sickness to strike, Taylor and her team proactively attend to the needs of the most at-risk patients. “We, as nurses, must always walk beside our patients and view the path/goal from the lens of the patient, while practicing our own art of care, advocacy and compassion.”
The rural nature of the area can make it challenging to procure certain supplies and transportation for remote patients. “This is where we have to get creative,” said Taylor. “We have to leverage our connections — within our communities, and within the healthcare system — to help bring resources to those who need them.”
Taylor says she and the care managers leave at the end of each day feeling like they’ve made a difference. One homeless patient who received support from Care Management to get back on his feet came in to show his nurse his first paycheck. “They celebrated that moment,” said Taylor. Another patient, who never felt good about herself, worked with one of the nurses to change her lifestyle. With coaching and support, she’s now active, eating healthy foods and feels in control of what is happening to her and her body for the first time.
This year, the nurses will continue their work with seniors, aiding in the home and helping with fall risk assessments. They will also keep offering support, education and resources for those who struggle with food insecurity.
While Care Management focuses on at-risk populations, any patient within the St. Joseph Healthcare system can get support from the Care Management team — no formal referrals or insurance required. “We are all connected within our community,” said Taylor, “It’s those connections and our experience that helps us to build the knowledge we need to help folks.”
To schedule an appointment with the Care Management Department, call 207-907-3333.