At the September 11 Steering Committee meeting, a case study was shared from the State Innovation Model (SIM) care coordination pilot.
For this SIM client, the care manager was able to find a new primary care provider, the IHA Pain Clinic, and a referral to physical therapy. The community health worker was instrumental as well, scheduling transportation, providing information about additional community resources, and obtaining new furniture following a bed bug infestation.
Per the participant’s self-report, it was extremely beneficial to have someone to check in on him in the community: “If it wasn’t for the clinical-community care coordination model that SIM offers, it’s possible this participant would have been lost to care and not able to achieve many of these goals.”