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Learn how the Full Frame Initiative partnered with Maimonides Medical Center and the Brooklyn Health Home to support care managers on the pathway to patient-centered care.
“You’ve got to take your medication,” the doctor explained to Maxine* as she recovered from pneumonia in the intensive care unit (ICU). The doctors were sure that the pneumonia set in when she stopped taking her HIV medication.
This wasn’t Maxine’s first time in the hospital. The case managers there had developed multiple plans to help her manage her HIV, but it seemed like Maxine wasn’t following them. So why weren’t the plans working?
The doctors didn’t know that Maxine had stopped taking her medication because she was afraid her roommates would kick her out for being HIV+. She hid her medicine in her closet, but they needed refrigeration. When she took them, the side effects – diarrhea, weight loss and fatigue – took away what made Maxine feel like Maxine: church, dancing, being part of her neighborhood’s Haitian diaspora.
Often in healthcare, we think health comes first and belonging, safety and other aspects of wellbeing will follow. But Maxine’s story isn’t unique. When health undercuts our wellbeing, we can’t prioritize our health.
In 2019, with support from the Robert Wood Johnson Foundation and the Center for Health Care Strategies,
Maimonides Medical Center launched a pilot to put patients’ needs at the center of care plans. Their extraordinary team made great progress, even as COVID ravaged the community. Yet their care managers continued to face challenges translating the ideas behind patient-centered care into practical tools
In 2021, the Full Frame Initiative (FFI) partnered with Maimonides and the Brooklyn Health Home to support care managers on the pathway to patient-centered care. We focused on a program for people dealing with chronic physical and mental health issues.
Supervisors co-designed the process, leading to more ownership over the changes they were being asked
to make. Supervisors also realized that care managers and patients shared the same concerns – isolation, racism, poverty – while coping in a community hard hit by the pandemic. In order for
the managers to work with people, not just patients, the supervisors had to shift their style to focus on people, not just workers.
Workshops, coaching sessions, tip sheets and other “nudges” to the system focused case planning on wellbeing. Small shifts like asking a patient early on, “Tell me something about you I’d never guess from your medical record” mean that this is not a longer or more complicated process. It’s just a different process.
For Maxine, care managers recognized how important dancing and community were to her, and adjusted her diet plan and treatment to reduce the side effects of the medication. It meant a modest purchase of a mini-fridge for the back of her closet. Maxine is healthier not only because she’s taking her medication, but because she’s safe, active and socially connected.
Our partnership with Maimonides grew out of a shared vision for patient-centered care and the drive to implement long-term, systematic change. Front-line providers began to notice barriers to wellbeing, re-examining things like patient assessment forms or how they spent time with each patient. Supervisors developed new tools to support staff wellbeing during the heights of pandemic stress. For Maxine and patients like her, translating patient-centered care into practical tools for care managers leads to better overall health.
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