At the Camden Coalition, our “high-touch” care management philosophy historically meant that we only did face-to-face relationship building. This distinguished us from many models of telephonic nurse care management with large panel sizes and limited interaction. When I first started at the Camden Coalition as an Enrollment Specialist, my entire job revolved around meeting people at the hospital bedside and enrolling them into our Camden Core Model care management program. We found that meeting people in the hospital before they were discharged helped our care team connect with them in the community, where we could build relationships through in-person home and community visits and make great strides in their healing.
In 2017, the Camden Coalition was named one of 32 local hubs across the country selected by the Centers for Medicare and Medicaid Innovation (CMMI) to participate in their Accountable Health Communities (AHC)* Model, which aims to screen for and address the social needs of Medicare and/or Medicaid beneficiaries. We knew this would mean a big shift in our navigation model. The AHC Model involved a huge increase in the volume of participants, an expanded geographic footprint from focusing on primarily Camden City to working with individuals throughout Camden, Burlington, and Gloucester Counties, and a shift in focus from those with the most complex medical and social needs to any Medicare and/or Medicaid beneficiary with social needs. All of this meant we would have to build our capacity for using telephonic case management.
To be honest, at first, I was skeptical. When we started AHC I worried that we would lose valuable information over the telephone. In face-to-face encounters, visual cues helped me gauge a patient’s emotional state. Without the patient saying a word, I could visually look at them and tell if they were happy, sad, angry, or in pain. That alone would help me determine how I was going to engage with the patient. However, after four years of telephonic engagement and relationship-building through AHC and two years of telephonic care management due to the COVID-19 pandemic, I now feel that building genuine therapeutic relationships with participants over the phone is not only possible but often necessary, given the high rates of needs we have in our community. In fact, during the pandemic, telephone outreach became a lifeline for many of the people we served, allowing them to access critical food, utilities, and housing resources.
Telephonic care navigation through the AHC Model
The AHC Model tasks hubs like the Camden Coalition with bridging the gap between healthcare and social services through screening for social needs, referral to local resources, community navigation services, and the alignment of regional partners. I was responsible for managing our screening, referral, and community navigation services. We worked with hospitals and clinics across Camden, Gloucester, and Burlington Counties, training their staff to use the standardized AHC screening tool developed through the Centers for Medicare and Medicaid Services (CMS).
Participants who screened positive for at least one health-related social need would receive a tailored list of referrals to community-based service providers through our My Resource Pal platform. Navigation services were offered to those with at least one health-related social need who had also visited the emergency department more than once in the last 12 months.
Community health workers (CHWs) at the Camden Coalition provided telephonic navigation services. They would take the time to interview the participants to understand their needs, develop an action plan using our COACH framework, and follow up with them on a weekly or monthly basis until either their needs were met, or we determined that they could not be resolved.
Making COACH work over the phone
Our COACH framework is the foundation of our face-to-face care management work, and with a few tweaks, it became an integral part of our telephonic outreach as well. One element of COACH is “Observe the normal routine” to see what participants can already do on their own. Since we could not meet the patients at their home or in the community to observe their normal routine, we asked them a series of open-ended questions to get a better understanding of what has happened in the past and what is going on now.
Another COACH element is “Assume a coaching style.” Based on how much support a participant needs, we decide whether to use a coaching style of “I do,” (care team member does the task for the participant), “we do,” (care team member and participant do the task together) or “you do” (participant does the task on their own). Over the telephone, we learned that we often had to be more direct in assuming a coaching style. We asked directly if they could do certain things like fill out applications, contact an organization that could advocate for them, or understand the process and steps of each task.
It clicked for me that telephonic care management could work shortly after we launched the AHC Model. It was around the holidays, and I was calling a participant, “Jeanette,” who had screened positive for food insecurity. I could tell as soon as she picked up the phone that there was something off. She sounded like I had just woken her up, and when I asked her if I had, the way she said “No, it’s ok, I’m up” prompted me to start the conversation differently to see if I could figure out what was going on.
After introducing myself, I asked Jeanette what was going on and told her I might be able to help her. She let me know that she just got custody of her grandkids unexpectedly and was stressed because the holidays were coming up and she was worried she couldn’t provide what they needed. Using our COACH framework, I was able to connect her with resources to help her and her grandkids, including.
Letting her choose what she wanted to focus on and what she wanted to share and reassuring her that I would be staying in touch, helped me form a secure, genuine, and continuous relationship — what we call an authentic healing relationship — with Jeanette, even over the phone. We were able to create a plan together (another element of the COACH framework) for her to get connected to resources. For some, she just needed the information and felt comfortable calling herself, and for others, she wanted my help making the call. Using COACH, I was able to give her the tools to advocate for herself and her grandchildren.
Telephonic case management is not easy, but over the years we learned and honed our skills fostering authentic healing relationships through secure, genuine, and continuous communication even if it lacked face-to-face contact. Our CHWs were able to convey the message over the phone that they were there for the participants, and they would advocate for them.
I had to rethink how I approached patient care and involvement after learning about the Accountable Health Communities Model and COVID-19. I have learned a lot over the years, including the fact that we did not need to reinvent the wheel when it came to telephonic engagement. All we had to do was adapt what we had already learned through our COACH framework to make it work. Without face-to-face interaction, we are still able to deliver patient-centered care and feel connected to people through telephonic case management.
Our AHC Model program wrapped up in June, but telephonic case management gives our care team another tool in our toolbox for all of our care management programs. It removes geographic and scheduling limitations, allowing us to reach people who are working or otherwise unable to meet with care team members during the day, and allows our CHWs and other care team members increase their productivity and handle more individual cases.
I was glad to be proven wrong about telephonic care management. As we begin enrolling participants into our rebooted Camden Core Model, I’m looking forward to being able to meet them where they’re at — whether that’s in person or over the phone — and knowing that either way I can confidently use COACH to connect them to the care they need.
*This project is supported by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $4,500,000.00 with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the U.S. Government.