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New program coordinates plans for better health

A new service in town coordinates care to help people meet their health care goals.

The Medical Home program arranges a care coordinator who works in partnership with a patient and their primary care providers, specialists and families – a health care team – to improve the patient’s health outcomes and quality of life.

“Basically, Medical Home is the deliberate coordination of services,” said Terri Swenson, RN and Medical Home coordinator for Alexandria Clinic.

A care coordinator works with the patient and their medical providers to develop a care plan.

Each care plan depends on a patient’s needs.

“The care plan we do is patient-centered. The patient sets their own goals because that will, in turn, help get to the doctor’s goal for that patient. If a patient needs help getting in to see their specialist, we can help coordinate that for them. If there’s a need for medication reminders or appointment reminders, we do that for them. Sometimes it’s just a matter of working with different entities – public health, home services – to make sure these patients get what they need,” Swenson explained.

The care plan considers the whole person, not just one part or problem. Swenson added, “We expect them, as a participant in [Medical Home], to take responsibility for their health as much as they can. If your doctor told you that you have to lose weight, then we’ll set up a dietician for you and after you meet with them you’re expected to cook healthy meals. We expect you to go for a walk, as much as you can do. Then, when you meet goals, we’ll set new ones for you.”

The program addresses a range of health care situations for all ages, including pregnancy, well-child care and chronic illness care.

“It’s kind of like having your own personal medical concierge,” Swenson said.

Medical Home staff will also work to coordinate a patient’s out-of-town medical appointments.

According to the Minnesota Department of Health, people with a Medical Home have fewer hospitalizations and miss fewer days of work or school.

An emergency plan is also part of each individual’s care plan. For example, it will be noted in a diabetic patient’s emergency plan that if their blood sugar is over 400, they should go to ER, but if blood sugar is 300-400, they should call the triage nurse for instruction.

“Hopefully we can eliminate some of the ER visits with that emergency plan,” Swenson said.


The Medical Home program is part of Minnesota’s health reform law passed in 2008.

The legislation includes payment to primary care providers for partnering with patients and families to provide coordination of care.

Swenson said Medical Home was designed originally to reduce costs for emergency room visits and in-patient stays. “With Medical Home, we provide education and coordination to say, ‘You don’t need to go to the ER for an ear infection, you can see us at the clinic.’ That kind of education goes a long way to saving health care dollars.”

“A lot of patients are not deliberately non-compliant, they just don’t understand,” she added. “The biggest thing I hear from patients is: ‘I feel like my opinion doesn’t matter,’ or ‘My doctor is overwhelmed and they don’t explain things to me.’ Sometimes it’s just a matter of re-explaining things in a way they can understand.”

The local Medical Home program is still in a trial phase and has had 12 patients enrolled since last October. The program is slated to be certified by the state in the fall of 2014, making it the only certified Medical Home program in Douglas County.

Patients can participate in the program as long as they choose and may opt out anytime. A physician can refer patients to the Medical Home program or people can self-enroll.

For information about Medical Home, call (320) 759-4004.

Amy Chaffins

Amy Chaffins is a journalist working for the Echo Press newspaper in Alexandria, Minnesota.

(320) 763-3133