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Care Coordinator Spotlight: Kayla Wagner


Kayla Wagner
RMHP Outreach Coordinator, Larimer County
Kayla Wagner hasn’t always worked with parolees, but she has always been interested in health care. For years, she worked on the administrative side, first in a clinic and then with a health plan. But a little more than four years ago, she discovered her true calling was more hands-on: helping others access the care and resources they need.
As a Rocky Mountain Health Plans outreach coordinator, Kayla works directly with members of Health First Colorado (the state’s Medicaid program) every day. “All of my life, my passion has been to help people,” Kayla says. “This is one way to do that.”
Based in Fort Collins, Colorado, Kayla and her nine colleagues help more than 44,000 Larimer County Health First Colorado members who need care coordination for mental, physical and behavioral health needs. Kayla works with people of all ages and a range of needs. Her focus, however, is the criminal justice system; she helps those recently paroled make the transition to health care in the community.
“The biggest goal when someone is released from the criminal justice system is to get them connected to a behavioral health or primary care provider as soon as possible,” Kayla says. Finding a doctor in the community isn’t usually the top item on a parolee’s list, but for those who take prescription medications, it’s essential. “They’re only released with a certain amount of medications,” Kayla says. Without a primary care provider or, in some cases, a behavioral health provider, medications can lapse and exacerbate health issues.
Kayla and her colleague work closely with the parole board to ease the transition. They use a secure video communications line at the parole office to call those soon to be released so they can connect them to a provider and help them access other resources they need, such as transportation to an appointment, help finding a job, or assistance in applying for housing.
A fairly large proportion of recent parolees are homeless, which introduces its own set of barriers to achieving optimal health.
”If you’re homeless, your first thought isn’t ‘I need to go to the doctor.’ It’s ‘where will I sleep tonight,’ or ‘where will I get food.’ Unless they’re in pain, medical need is their last thought,” she says. That’s what drives Kayla to actively reach out to parolees wherever they are—in clinics, at shelters and in the community.
Kayla’s work also involves face-to-face meetings with Health First Colorado members to assess their health needs and create a care coordination plan that works for them. After a member is hospitalized, Kayla or one of her colleagues reaches out by telephone to ask if they need help finding a primary care provider for a follow-up appointment, or to coordinate other needs such as home meal delivery, special equipment or transportation. Members with complex health needs may receive ongoing care and assistance.
“The system has so many resources available, but the hard part for members is knowing where to start and moving from one step to the next,” she says. “We’re able to help make phone calls and get the resources they need, and also to just to help people get through some of the toughest times.”
That’s what’s most rewarding about the work, she says.
“I’m not always going to be able to fix something. But the moment when people are so thankful for even the simplest thing—that makes it worth it. Members tell me, ‘you called at the perfect time, when I needed you.’ Sometimes, people need to know there’s someone out there who cares. If that’s all they need and I can provide it, that works for me.”