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Health Care Home Services in St. Paul MN



Health Care Home FAQs

Q: What is Health Care Home?

Answer: HCH is a team approach to your healthcare. Your team consists of your doctor, care coordinator, RN, and you. Each member of the team helps determine your unique health needs and provides you with the best possible care. You will continue to follow up with your doctor as usual; however the added component is contact with your care coordinator or RN in between visits. This contact is typically a phone conversation, but it can also take place in person at the clinic.

Q: What do these follow-up conversations involve?

Answer: Your care coordinator or RN will work with you and your physician to determine your unique healthcare needs. Follow-up conversations may involve goal-setting, discussion and referral to resources (i.e., social worker, caregiver assistance, therapist, psychiatrist, home health care, PCAs, etc.), and medication follow-up. Any questions for your doctor can also be discussed at that time. See below for examples.

Q: How long will these conversations last?

Answer: Each conversation may last from a few minutes to approximately 30 minutes, with the initial meeting lasting longer than the future meetings.

Q: How often will I speak with my care coordinator or RN?

A: A typical time frame includes a follow-up conversation halfway between each visit to the doctor. However, your care coordinator or RN will work with you and your doctor to determine an appropriate time frame. As your healthcare needs change, the length of time between follow-ups may also change. You are also encouraged to contact your care coordinator or RN at any time if you have questions or concerns about your health or medications.

Q: Who can be a part of HCH?

Answer: Any patient at Entira can be in HCH. However, the patients who typically benefit the most may have one or more chronic conditions such as diabetes, heart disease, depression, anxiety, high blood pressure or high cholesterol. Patients who try to lose weight or quit smoking commonly benefit as well.

Q: Can care coordinators and RNs work with family members of a patient?

Answer: Yes. We oftentimes will work with a patient’s parents (for their children) or children (for their aging parents). The family members need not be a patient of Entira

Q: How much does it cost to participate in HCH?

A: There is no cost at this time.

Q: When do I “graduate” from HCH?

A: There is no specified length of time for the program. You can be a part of HCH as long as you are a patient of Entira or until you feel the program in no longer benefiting you

Q: How do I become a part of HCH?

Answer: Ask your doctor at your next clinic visit, or call the number for your clinic’s care coordinator (found below).

Sample Situations

You have just been diagnosed with diabetes.
Without HCH: Your doctor explains diabetes, gives you a prescription, and tells you to come back in three months.
With HCH: Your care coordinator contacts you by phone in one week. You have some questions that you forgot to ask the doctor, and your care coordinator helps answer those questions and sets you up with diabetic education. Your medication has made you a little sick, so your care coordinator works with your doctor to adjust the dose. Together, the two of you set small goals related to your diabetes and agree to speak again in two weeks.

It's wintertime and you feel much more depressed than usual.
Without HCH: Your doctor gives you a medication and asks you to return in one month. You find the medication is too expensive and decide not to pick it up from the pharmacy.
With HCH: You call your care coordinator and explain your problem. Your care coordinator shows you an online prescription coupon website and helps you apply for the drug company’s savings program. Then, they match you with several therapists who take your insurance. Your care coordinator calls you in 2 weeks to administer the depression screening questionnaire and updates your doctor on your response to the medication. 

You are the sole caregiver for your mother, and you feel her memory has worsened. 
Without HCH: Your doctor refers your mother to a neurologist and starts her on a new medication.
With HCH: Your care coordinator has the records sent to the doctor after the appointment and calls you to discuss how she is doing with her new medication. Your care coordinator finds out you are stressed and overwhelmed and provides information about a home health aide and caregiver resource foundation. Your care coordinator completes the referral form and follows up in one month to set up your mother’s follow-up appointment with the doctor and find out if you were able to connect with the home health aide and caregiver resource foundation.

Read about the Wilder Foundation and their partnership with Entira Family Clinics.