Reflecting on the impact of this one-year-old program

Project Access Northwest’s Health Home Program marked its one-year anniversary in April. In 2017, we partnered with Coordinated Care to launch the program and provide services to its most vulnerable members. These individuals frequently have multiple chronic, debilitating conditions and, due to limited resources, lack stable housing and reliable access to communication with their providers. Our care coordinators meet these clients in their community and provide personalized care coordination, health promotion, support and resources. Frequently, we work with these members to help them transition successfully from the hospital or emergency department back to home. 

Health Home care coordinators help develop patient-centered Health Action Plans to support patients in achieving their goals.

Difficult but inspiring work

This intense care coordination work is difficult, but it is also inspiring! We see clients improve their health and obtain jobs and stable housing with the guidance and support of the care coordinator.  We help access resources that clients might have struggled to obtain, including glasses, dental exams and durable medical equipment, such as a wheelchair. We can attend medical and behavioral health appointments with the clients, to help advocate and clarify the need, so that the right care is received at the right time. If a client is diagnosed with a terminal illness, we provide emotional support to the client and also to the family throughout the process. 

Our clients often express that they feel hopeful and supported by having a care coordinator by their side as they navigate systems where they have been unsuccessful in the past.  

By the numbers

Today, four full-time care coordinators serve clients in Snohomish and King counties, with two administrative staff providing internal supports, documentation assistance, outreach and resource referral. And we have had very successful engagement! In the active 8.5 months of 2017, Care Coordinators met with 270 new clients, providing assessment and assisting them with creating a Health Action Plan that will help them meet health goals and overcome barriers to health needs. Care Coordinators also provided 733 face-to-face follow-up appointments during this time to continue to address the ongoing needs of these clients. Now, Health Home care coordinators follow approximately 52 clients per month, providing 35–45 face-to-face visits monthly.  

“We remain excited about the Health Home Program and the profound impact it has had on the lives of our most vulnerable patients,” says executive director Gary Renville. “The thank you notes and other comments we receive from patients prove that this approach is working. We’re helping patients get the care they need and reach the goals they’ve set for themselves.”