Networks of care provide medical excellence without the miles

Astoria doctors, better cancer care

Networks of care improve the quality and experience for patients. Left to right: primary care physician Dr. Angela Nairn, Pacific Family Medicine; general surgeon Dr. Juliette Moore, CMH General Surgery Clinic and Oregon Health & Science University; general surgeon Dr. Rachel Van Dusen, CMH General Surgery Clinic and Oregon Health & Science University; and radiologist Dr. Houman Sabahi, Pacific Coast Imaging.

CMH caregivers are working with primary care providers, patients and organizations throughout the region to create streamlined networks of care that meet each person’s needs throughout their life. Two of these care networks are the newly operational Breast Health Program and the Maternal-Child Care Program.

Breast Health Program provides seamless care

CMH is working with primary care providers throughout the region to quickly diagnose and care for patients with breast tissue lumps. From the initial discovery of a lump to diagnosis and any necessary treatment, the Breast Health Program aims to be a care hub for those who need it. 

A team of CMH caregivers followed the many paths a patient might take when they have a breast lump. Using that information, they refined and improved CMH’s system to make receiving a diagnosis and treatment simpler and more comforting to patients. CMH now has a comprehensive and multidisciplinary breast healthcare network that serves patients from start to finish. 

“It’s a whole new process, a whole new paradigm,” says Jaizie Ziebert, Director of Surgical Services. “We looked at “What is the most compassionate thing for patients?”

Clinical nurse navigator guides your way

In earlier models of care, the patient had many stops along the path to receiving care. Now, patients are assigned a clinical nurse navigator who serves as their go-to person for scheduling, questions or concerns. The nurse navigator coordinates all of the services the patient will need. 

Jamee Meier, Medical Group Director, says the purpose of the comprehensive program is to determine a plan of care for each woman or man with a breast tissue lump and make getting appropriate care as easy as possible. 

Following the initial phone call from a patient or a doctor’s referral, the program aims to have the patient seen by a general surgeon within one business day. After meeting with the surgeon, a plan of care is decided. If it involves surgery, Ziebert says everything is coordinated through the CMH Surgery Clinic. All patients need to do is show up — and the rest is taken care of. 

This refined experience shows more compassion and care for the patient. “We realized we were place-centered, not patient-centered,” Ziebert says. “The patient would go to give different places the morning of surgery. Now they go to two, and they’re driven between them.” 

Oncology nurse navigator guides cancer treatment

If a breast lump is found to be cancerous, the patient’s clinical nurse navigator introduces the patient to their oncology nurse navigator, who helps coordinate cancer treatment. 

Ziebert and Meier emphasize that the Breast Health Program is based on the promise of “Medical excellence without the miles” — a team effort involving independent medical providers, CMH clinics and services and the new CMH-OHSU Knight Cancer Collaborative.

For more information about this program and breast health, visit columbiamemorial.org/breast-health or call 503-338-4670.

Maternal-Child Care Program: Care from the very beginning

Another network of care provided for CMH patients is the Maternal-Child Care Program, which brings together the services of the Women’s Center and Pediatric Clinic. From pregnancy through birth and beyond, CMH offers an integrated program of care that boasts a quality not seen elsewhere in the region.

That quality is illuminated in the differences at CMH. The CMH Women’s Center and the Pediatric Clinic are home to teams of board-certified physicians, nurse midwives and pediatric nurse practitioners. “It’s a great service in a small community,” says Diane Hutson, Clinic Manager. “We have very skilled doctors, nurse midwives and social workers.”

Once a month, medical providers and caregivers from Pediatrics, Obstetrics and the Family Birthing Center meet to share information, discuss what is changing in their fields, determine best practices and examine how to put patients first. These monthly gatherings emphasize the teamwork needed to offer a program of whole-life care.

OB Centering: Support program for moms-to-be

This team is working to implement an innovative program called OB Centering. The idea behind this program is to foster a supportive environment for first-time moms whose babies are due around the same time. 

In the third trimester, the mothers-to-be would attend monthly checkups with private time for each mom and their provider and group time with other moms to ask questions and learn about prenatal care through discussions and activities. Topics of discussion could include anesthesia, labor and delivery, nutrition, breastfeeding and infant care, among others. Although OB Centering is not in place yet, Hutson says they are building the foundation of the program and hope to test it with a group soon. 

“We’re in this mindset of trying to figure out how the services wrap around patients from the very beginning,” Hutson says.

A social worker now meets with as many expecting mothers as possible to talk about services that might help them during their pregnancy, planning for life after the baby is born, postnatal depression and to complete ACE (adverse childhood event) screenings. 

Off to a great start

In the hospital, every newborn is examined by a CMH pediatrician. This gives new parents the opportunity to ask questions and establish a connection with the pediatrician who may care for their child as he or she grows.

To learn more about this program and the CMH Women’s Center, call 503-338-7595 or visit columbiamemorial.org/womens-center.

In creating these networks of care, CMH aims to provide appropriate care throughout all stages of life.

Read more from the Spring 2018 issue of the CMH Health Compass.