Laura Palmberg loves to solve puzzles—the search for missing pieces to fill a gap ends in satisfaction when everything cleanly connects. The board-certified case manager works for Rocky Mountain Health Plans as a Medicaid community health outreach coordinator, solving puzzles every day for residents of Garfield, Pitkin, Eagle and Summit counties in Colorado.
“Care coordination really does benefit everyone, because it helps people get the services they need so they can take better care of themselves,” Laura says. “Sometimes it’s just the fact that someone cares that makes the difference. I started going to doctor’s appointments with one client who didn’t have a primary care doctor and didn’t always understand what the doctor was telling him. Now he’s established with a primary care physician that he really likes. It make a difference in people’s lives to say, ‘I’m here. What can I do to help?’”
It’s a rugged and largely rural region. Few specialists serve residents here. Transportation is often an issue for residents without a vehicle; in Rifle, for example, there’s no taxi, Uber or Lyft service to take patients to a doctor’s appointment. But Laura and her colleague know the territory and can connect members to the resources they need to support better health.
“We’ve worked hard to establish relationships in the community, with providers and hospitals,” she says. “We have really good relationships with the departments of human services in our counties. We can literally connect members with the specific person who will be in charge of their case when they call and ask about a resource.”
Laura also works with emergency management services in the region to identify those who frequently use hospital emergency rooms because they have coordination needs. She works with schools in the area to facilitate support for students with social, behavioral and physical health needs.
“We’re exploring how we can support entire families to ensure they have the benefits they qualify for, and we work with schools to connect them with resources they may not even know about,” she says. “We can be the liaison who goes with that struggling student to doctor’s appointments, and then advocate for the student at Individualized Education Program meetings. We can pull those pieces all together.”
On a typical day, Laura checks on members who were recently discharged from a hospital to make sure they understand how to take care of themselves. “A lot of times they say, ‘I think they told me to take this medication, but I can’t remember for sure.’ Maybe they’re not thinking clearly because they’re really exhausted or taking pain medication. We can call the nurse for them and find out what they need to know, and explain it to them so they understand.” She arranges followup appointments and transportation to get there, when needed..
Laura helps members sign up for food and housing assistance or to pay utility bills, but lack of available resources is a real problem in the region. Behavioral health appointments can be hard to arrange, but integrated behavioral health in primary care practices in the area is making that easier. Affordable housing is a real challenge. “If you live in Rifle, the wait list for housing is 18 months to two years,” she says.
She meets face to face with clients when needed, accompanying them to appointments or just working with them to solve problems that impact health. “It’s a little bit of everything,” she says.
“I did a visit with a male in his early 30s who was living at home with a relative. He had a developmental disability. He had recently moved here from Seattle, and he was isolated from the friends and family he knew,” she says. “What he wanted was a job and to be out meeting people his own age. We got him connected with Mountain Valley Developmental Services, and now he goes bowling and attends their dances—he is so involved and engaged. When you see things like that happen in real life, it’s really rewarding,” she says.