Susan Butterworth, PhD, MS

Associate Professor, Oregon Health & Science University

President, Q-Consult

Chronic care management with commitment to patient-

centered approach

Collaboration between health care practitioners & community

service providers

Goal is improving health outcomes for high risk, complex

Medicaid cases

Population served have

multiple chronic diseases,

mental health issues &

history of substance abuse

RNs serve as care manager Partners: Aging & Disability Services, Senior Services,

community healthcenters, & Harborview Clinic

Access to team of health care professionals with clinical,

psychiatric, chemical dependency, social work and

pharmacological expertise

Outcome measures:

patient activation

utilization costs

clinical indices

One-day training in patient activation & use of Patient

Activation Measure (PAM)

Two-day MI training with staff and leadership

Identification of internal mentors

MITI coding and monthly coaching (skill-building) sessions

with mentors

Follow-up half day MI and Mental Health workshop

Identification of lead facilitator & support for self-

management of program

Decreased rate of successful follow-up; i.e. every contact

counts

Increased number of co- and multi-morbid conditions and

behavioral health concerns

Lower education and socioeconomic levels associated with

increased barriers to medical care, and lower healthcare

knowledge, ability to navigate system, and confidence levels

Increased level of defensiveness and feelings that system

has let them down

Increased level of cultural differences

traditional health care system views patients who do not

follow treatment plans as ‘non-compliant’.

In some cases, they are discharged from their primary care

clinic because they are deemed too challenging to work with

Medicaid patients who have dual diagnosis have pressing

social issues which take precedence over medical treatment

45 year old female with Russian origin; poor English

language skills and literacy

Homeless; living in tool shed with no electricity, plumbing,

and heat

Conditions: schizophrenia, PTSD, alcohol & tobacco

addiction, Chronic Obstructive Pulmonary Disease (COPD),

diabetes

KCCP care manager goals: get into public housing, address

addictions, address diabetes control, refer to mental health

specialist for review of meds

Patient goal: find housing that accept dogs

Intervention: Care manager successful in identifying housing

that accepts dogs as primary goal

Outcome (as of 9/30/10): Patient in public housing; has

agreed to mental health review; increased self-efficacy and

activation