How an FQHC Used Caseworkers for Chronic Disease Management

In the wake of workforce challenges, Bluestem Health outsourced caseworkers who have been instrumental in supporting the FQHC’s chronic disease management efforts. The Nebraska-based Bluestem Health knew whole-person care that accounts for behavioral health and SDOH would be the key to complex chronic disease management, but in the throes of a nationwide workforce shortage, the federally qualified health center (FQHC) wasn’t left with many options. After nearly five years of focusing on chronic disease management, leaders at Bluestem had determined that traditional provider-led health coaching couldn’t move the needle alone. The organization, which participates in the Centers for Medicare & Medicaid Services (CMS) Chronic Care Model (CCM), first deployed behavioral health strategies to uncover the barriers to patient engagement in care management.

“We know in our practice that if patients are coming to their appointment, they don't want to be non-compliant,” Brad Meyer, Bluestem Health’s CEO, told PatientEngagementHIT in an interview. “We've always known that patients don't ask their doctors questions, because they're afraid to look dumb or look a certain way during the visit,” Meyer continued. “And so they're able to talk to these behavioral health therapists a little bit more openly, and then the behavioral health therapist can then either relay that information to the provider or work with our certified diabetic educators or our chronic disease nurses to put more emphasis and focus on that patient.”

But as those behavioral therapists began to uncover some of the downstream factors keeping patients from optimal chronic disease management, it became clear Bluestem couldn’t go it alone. Many of the patients enrolled at the FQHC experience multiple social determinants of health, as well as other patient health literacy barriers that keep them from achieving wellness.