When things get complicated

It was after he came home from the hospital that things really got complicated for the Vietnamese patient. Follow-up appointments had been scheduled to help him heal and adjust to his leg amputation, and a dialysis schedule had been set up to bolster his failing kidneys. But with little support at home, he had trouble making it to his appointments. By the time he finally did see his primary care physician, the patient’s condition had deteriorated significantly. That’s when his doctor called in a case manager.

Case managers are part of the care team at all Providence Medical Group primary care clinics throughout the greater Portland and Newberg areas. These unsung heroes get called in to help when things get complicated. They may not run faster than a speeding bullet or leap tall buildings in a single bound, but they do employ a much more essential super power when coming to the aid of people with complex medical issues: they make connections.

They connect with patients to help untangle complex health and social situations. They build connections among the multiple providers involved in a patient’s care. They get connected with family members to educate them and assist with home care issues. They help patients and families connect with helpful resources. And they connect with people on a personal level, as advocates.

When case manager Judy Sims, RN, was called in to help with the Vietnamese patient, the first thing she did was to bring in a translator to facilitate a discussion with the patient and his family. When family members explained the difficulty in getting the patient to his appointments, Judy called TriMet’s LIFT program and arranged transportation for him. When she learned that his limited English was making it difficult for him to understand his medication instructions, she referred him to a new pharmacist with a Vietnamese-speaking staff member who could explain things to him. Ultimately, when a readmission to the hospital made it clear that the patient needed more support than he could get at home, Judy connected with the county and found a Vietnamese adult foster home to take him in. “He had a wonderful Christmas that year,” she says. “Now he makes it to all of his dialysis and doctor’s appointments, and he hasn’t been readmitted to the hospital since.”

Helping patients to prevent avoidable hospital and emergency department visits and to receive the services they need to improve their health are two goals shared by all of Providence Medical Group’s case managers. “It really takes a team – and sometimes a very broad team – to meet the needs of people who have complex medical issues,” says social work case manager Jenell Neufeld. That team may include the patient’s primary care provider at Providence Medical Group, home health providers, Medicaid case workers, health plans, transportation services, financial assistance counselors, pharmacies, mental health providers, chemical dependency programs, elder care organizations and a multitude of other resources, both within Providence and with community partners. It can get complicated, but the case manager is there to help. “We collaborate with all of the entities that are part of a patient’s environment of services,” says Jenell. “We really take to heart our responsibility to ease people’s way.”

Admittedly, not all problems can be fixed entirely. Even so, says Jenell, “When patients tell us that they feel better just having talked to us – that’s a success. Because if we’ve lowered their distress about something, we know that they’ll be able to focus more attention on their health.”


If things are getting complicated for you, or for a patient in your care, make an appointment to talk to your Providence Medical Group primary care provider.