Interview – Shelle Berg

Two years ago, I was hired as the accountable care organization care coordinator, to facilitate the transformation of care for accountable care organization initiatives. My office is based in the clinic, but I do participate in all the discharge planning meetings three times a week and our care conferences that we have. I work quite closely with the social worker. We’ve formed a care management team. The inpatient care coordinator, RN, social workers and I hold discussions on a daily regarding our patients that are high utilizers or frequent visitors to the clinic. We discuss resources that could assist us, social determinants and barriers of care.

I also manage or help facilitate our patient center medical home recognition process that we are doing with Blue Cross Blue Alliance ACO. I am a lifestyle coach for the diabetes prevention program that we just started in April and a population health nurse. I also belong to four or five coalitions in the county. One is behavioral health. One is substance abuse. One is the well child coalition in the state of North Dakota and another is domestic abuse and wellness coalition for our county.

When I first was in contact with her, she was having quite a few visits to our emergency room as well as admissions for weakness. She wasn’t checking her blood sugar. She wasn’t taking her thyroid medication consistently and she was coming into the clinic off and on. The physician’s assistant was a nurse for years and was her key person, but of course, that provider has clinic patients and was in the ER. So, I would take calls, so the patient would have a connection with our healthcare facility when she came in on a reactive basis.

With that, we started care management or care coordination with her. I explained to her that we were going to be taking care of patients in a different way and we were going to have a partnership with her so that in between her clinic visits or her urgent needs, we were going to help her with a plan of care to self-manage herself at home and we were going to coach her and be her cheerleader.”

She’s like, “Okay, well I guess I’ll give it a try. Yeah, you can call me.” So, we started out where I would call her every couple of weeks and I realized within the first two weeks and within those first calls, she was not taking her Synthroid. She hadn’t even refilled it.

We went from setting up her medication in a pill box to talking to the pharmacist and the pharmacist realizing that I was a part of her health care team management. We put a note into her healthcare records saying that she’s being managed with a clinical health coach and that I should be contacted with any updates or changes that are made outside of the care center.

It was a great pilot project and the patient eventually would say once or twice a month, “I guess this is a good thing. I’m doing better.” She also started paying attention to her sleep patterns.

She started accepting the services that were there for her… accepting home delivered meals, accepting the homemaker services, accepting help from the county for costs for her heating. Just building her up to the point where she felt that she was important enough to be living and have a purpose was key.

So, when I came to work on one Monday morning, she had left me a voicemail and she said, I’m just calling you because you’ve been gone to conference for three days and I managed to take care of myself. I wanted to tell you I’m so grateful. Sometimes I can’t tell you that on the phone because I get choked up, because I’m so alone. She was grateful for the whole health care system at First Care Health Center. She said she realized the healthcare center was better than she expected and was appreciative that they were able to put a nurse on the phone to help her, and that nurse was me.

So, it was a great thing to hear on a Monday morning.

She went to our stepping on classes, which she would have never done before. So, I feel we’ve made a difference in her life.

We’re working with other clinics as we only have one clinic in our small city. There are clinics 45 minutes from us that we try to work with closely. Sometimes we share the patients in a way because they might come here for primary care, but they have a small clinic that’s associated to a larger health system in another rural town. And so, yeah. We’re working hard at it. And we’ve been pretty successful as a team to do that. It’s a workflow change. It’s huge.

I would say probably some of the impact that I feel is with the diabetic population of patients that are in their thirties or forties who have been diagnosed with prediabetes, and then type two diabetes. They’re dealing with envisioning the process of probably starting on insulin. I’ve had a few patients like that where a provider that especially understands health coaching will call me in, and we meet with the patient together, face to face. The provider will explain the difference of health coaching vs a nurse’s typical process of nurse education support.

We have one gal, I would say she’s in her mid-fifties. I probably worked with her for six months. And she was exhausting to the rest of the healthcare team that she had already visited with. She was way too sick for a woman her age. Her blood sugars were up into the mid-300s on a daily basis. And she had stomach upset, and pain, and she constantly got upper respiratory infections. She was depressed, anxious, and moody.

When we started working together, it took some patience. I told her we just needed to set a couple goals for her, before we end the call. I asked her if she would be willing to share with me what would help her. What you could take pride in and what would make you want to improve your health? And I think the one thing she said was, I’ve been miserable ever since I got divorced, and I want to own my own happiness and get back to it.

And then she kind of got back to some of those things, and it helped her to write it down and put it on a calendar. And I used the confidence ruler, at times when we would get close to the call, I’d say, well, I’m going to bring out that ruler again like we do the pain scale, but we’re talking about good things here now, and things that you’re working on to improve your health. How committed can you be to contacting that friend to walk every night? Do you think you could, from zero to ten, rate that commitment and that confidence? And she’d say, well, I think I can give it an eight this week, because two weeks ago I gave it a four and I did it.

We then moved on to weight loss because she knew that if she worked on her weight, it would help her whole health. She already was dropping pounds, and adjusting her nutrition, and taking her medications efficiently, and we overcame the barriers of the cost. Now she’s on Victoza, which is not an insulin. I am still working with her and is was just yesterday I was able to do a face to face with her. We just talked about how she felt she had been doing and what was going on in her life. I asked her what the biggest thing that was bothering her health? And she said, I’m just getting to the point where I’m just so ticked off all the time, again.

And my stomach hurts when I get like that.

Health Coaching is a good thing for nursing. I love listening to the Clinical Health Coach training and have used the skills I’ve learned on a daily basis. I sometimes think I can’t take time to refresh my skills and then I tell myself, no, it’s going to recharge your battery. Listen to it. It is a wonderful program that you guys have and your education is very inspiring.