Pell City’s Northside Medical CARE Team has launched a premier program tailored to meet patients’ needs, even if it requires the medical team coming directly to the home. It is the first of its kind in Alabama.

      The CARE Team concept was launched at Northside in April. Created by Northside founder and CEO Dr. Rock Helms, CARE Team serves as a bridge to a better quality of life for patients. Hospitalizations can become a “revolving door” for them (patients), Dianna McCain, CARE program director, explained but “you have to find the root cause of the problem to provide an accurate solution, there is no other way to do this than building that personal relationship with our patients to provide them with the highest quality care possible”.

      The CARE program consists of a nurse practitioner and four medical assistants. Beginning with four patients, it has now topped the 200-mark and is growing daily with plans to expand their team to include social workers, nutritionists and mental health workers as it continues to grow.

      Northside and all its clinics in St. Clair County and East Jefferson County are referring chronically ill and at-risk patients to the team, but referrals can come from anywhere – a caregiver, a doctor, family member or friend. The aim is to reduce hospitalizations and enhance their quality of life. “We want them happy, healthy and out of the hospital. That’s our main goal,” McCain said.

      An initial visit to the home usually involves a nurse practitioner, which assesses the patients’ medical and non-medical needs and initiates a plan of care for that patient. The patient’s history, blood pressure and other vital signs are taken. Lab work is done, and if needed, X-rays can even be done in the home. Just as important, the patient’s social situation is assessed including caregiver stress or lack of caregivers, issues with isolation, transportation, lack of adequate nutrition, financial barriers to medical care, and medication compliance problems, just to name a few.

      Based on the initial assessment, physical therapy and occupational therapy may also be ordered – “whatever we think is needed” – can be arranged. The CARE team works with the patients to develop a care plan for them, “and our team works with the patient to follow it,” McCain said.

          Beneficiaries from the CARE program are patients with Dementia or Parkinson’s Disease who together with their caregivers are struggling. Patients with complex health issues such as Congestive Heart failure or Lung Disease with frequent doctor visits and hospital stays and multiple specialists need help. They need better care coordination among all the patient’s specialists and primary care and hospital stays to reduce hospitalizations and improve their quality of life.

      Chronically ill patients, like those suffering from Diabetes, high blood pressure, depression, chronic obesity, renal disease and COPD are targeted in the program.

      Dr. Helms and his partners at Northside realize that our country’s health system falls short in caring for the sickest and most vulnerable patients. The CARE team is Northside’s approach to tackling this critical issue in our nation’s health care today because, they say, the primary care relationship with their patients puts them in a unique situation to accurately identify barriers to their patients’ health and to put a plan into place to navigate around those barriers.

      The CARE team serves three main functions – ensuring coordination of medical care with their primary care doctor and the health system; functioning as a navigator through the health system and a central hub that connects patients and their family to whatever resource that they may benefit from in the community and elsewhere; and providing direct patient care by phone 24 hours a day, 7 days a week. If phone calls are needed every day or home visits indicated CARE follows through.

      Some of the services the CARE Team provides includes going to many of their patients’ homes and assisting with medications on a weekly basis, or they might call daily to remind patients to take their medications. The CARE Team finds resources and agencies to work with patients as well.

               As an example, McCain talked of a Northside patient who has been a patient of the practice for 15 years. After the patient’s last hospitalization, he couldn’t walk and he had no walker or wheelchair. “We found an agency to work with to help with the physical transition back to his house, by donating supplies, helping build a ramp and making other modifications,” McCain said. “Without these modifications, he would have had to find housing elsewhere, he had nowhere else to go, so we helped.”

      The CARE team, along with other members of the Northside team, cleaned and painted the house themselves. “Dr. Helms realizes that it’s not always a medical condition that has anything to do with medicine. It took love, compassion and help … a labor of love from the Northside team.”

      As for patients in the program, “They’re amazed,” McCain said. “They say things like ‘I can’t believe anybody cares anymore’ or ‘I can’t believe a doctor is going to come to my home.’ They’re sometimes skeptical at first, worried at how much it may cost, but they are always so thankful when they realize it’s just part of the care provided by Northside and their providers.”

      Because of the growing shortage of primary care physicians, Helms envisioned a program that could take the best care of patients, whether it is in the office or at the patient’s home. “That is one of the reasons why this program started,” she said.

      “We can help people with anything, we just need to know the need. We don’t want people to feel that there is no hope. They have someone to turn for help.”

      Those wishing to donate or volunteer with the CARE team, contact McCain at Northside Medical Home at (205) 814-9284.

Submitted by Northside Medical