JCHC receives award for care management programs

FAIRFIELD – Jefferson County Health Center patients are benefiting from a couple of new programs, one to treat patients recently discharged from the hospital and another to treat chronic conditions.

Bethany LaRose is a licensed practical nurse at JCHC, and she is the case manager for these two programs called Transitional Care Management (TCM) and Chronic Care Management (CCM). TCM is a four-week program for patients who need additional support after they’ve been discharged from the hospital. LaRose said this includes weekly phone calls and assistance with things such as education, medication adherence, appointments and transportation. CCM offers the same type of resources for an extended period of time.

LaRose said these programs are available to people 65 years and older, and who have either Medicare or Medicare Advantage. Patients must have a primary care provider at JCHC. LaRose said that, to qualify, patients must have two complex care conditions such as heart disease, chronic obstructive pulmonary disease, or diabetes.

LaRose said the CCM program began first, and from that TCM was developed. It started through a Medicare grant and partnership with the University of Iowa. JCHC Nurse Tracie Durflinger started the program, and even though the original grant has ended, the program has continued to grow. LaRose said these programs were responsible for creating and distributing the first Jefferson County Resource Guide.

LaRose noted that in September 2023, the TCM/CMM Program received the award for Achievement in Improving Care Transitions for the state at the Iowa Healthcare Collaborative Patient Safety Conference.

LaRose has worked at JCHC for 10 years, first as a nurse on the medical surgery floor. Then she left JCHC to work at an assisted living facility in town, and came back to JCHC to work in its rural health clinic during COVID. About two years ago, she moved into case management and has been doing that ever since.

About half of her time is devoted to the TCM/CCM program, a responsibility she shares with fellow nurse Julie Ostby. They see about 5-10 TCM patients per week, and about 35-45 CCM patients per week. LaRose said that, since she and Ostby are seeing the same people week after week, it has allowed them to build a great rapport with their patients.

“During our TCM, that’s when we’re building our rapport with them and setting that foundation, and a lot of times they’ll transfer into our CCM program where we continue to help them with whatever needs they may have,” LaRose said. “I look at them like they’re my friends, not my patients.”

LaRose said JCHC is working with Davis and Van Buren counties to expand the program into those counties, too, by creating a Complex Care Network.

  Buy Photo

Call Andy Hallman at 641-575-0135 or email him at andy.hallman@southeastiowaunion.com