Case managers help patients get the resources they need to achieve better health—whether it’s a ride to a doctor’s appointment or help paying an electric bill. Patients with complex health concerns in particular can become overwhelmed as they try to manage health-related burdens: multiple medical appointments with specialists and primary care providers, new medication regimens, financial challenges, and even diet and exercise changes—all while maintaining family and work commitments.
Nancy Soltero’s job is to be the complex patient’s advocate and voice. Soltero has been part of the Mountain Family Health Centers team since she started as a medical assistant there in 2005. She advanced to become lead medical assistant, and then earned nursing credentials, changing roles and responsibilities along the way.
And when Mountain Family began its complex patient case management practice five years ago, it was Soltero who first filled the role—and who now supervises the three case managers in the practice.
“A lot of patients are not able to advocate for themselves, so we really try to advocate for them and try to empower that patient to be their own advocate,” she says. Soltero helps patients understand the steps needed to follow up after an appointment, for example, and then checks back with the patient later to ask how the therapy, treatment or appointment went. “Sometimes we offer to make the phone call with them--to order diabetes supplies for the first time, for example. When we do it with them they can see how it goes, and then they can do it the next time themselves.”
Empowering patients is critical, because doing everything for a patient is often not in their best interest. “For a patient to be able to make a change, they need to be ready,” Soltero says. “They may not be ready to do everything, so we have to listen and help them do what they’re ready to do.”
Case managers help Health First Colorado patients access resources to help along the way, because they understand what transportation, housing and other supports are available and how to apply for services.
“One of my biggest goals is to see where that patient is in that moment,” Soltero says. “I might think there is one problem, but once you start talking, it could be that the reason they can’t do something is totally different from what I thought.” For example, a patient may not be taking medication because they can’t pay for it and still pay the electric bill. “That’s where I think, where is this person right now? What can I do to help?”
Soltero is bi-lingual, so she can also communicate one-on-one with Mountain Family’s many Spanish-speaking patients. “We have people here from different countries that speak Spanish (Soltero speaks Mexican Spanish, but many locals are from El Salvador, Guatemala or other countries), and they’re really more open to talking to a Spanish-speaking person, even if it’s not exactly the same,” she says. Because much of her job relies on careful listening—to read between the lines and uncover barriers to care--Soltero takes on most of the case management needed for Spanish-speaking patients at Mountain Family.
“What I love best about what I do is helping our patients understand what’s going on with their health,” she says. Soltero and her case management team help patients set and reach their own goals, and they walk along with patients on their journey to better health. “I can actually be part of that patient’s life from the beginning, when they get a complex health diagnosis, and really see what the outcome is after we’ve helped—I’m with them the whole way,” she says. “It’s really nice, because I know this is where the patient started, and this is where she is now.”