Wheat Ridge, Colo.,
12:37 PM

Lutheran Medical Center's “Unsung Heroes” – Care Management

Lutheran Care Management

Well-deserved recognition and praise are given to our doctors, nurses and other clinical staff who provide direct care for our patients. However, there are hundreds of behind-the-scenes caregivers who play a vital role in making sure hospital operations run smoothly while ensuring our clinical caregivers have everything they need to provide our patients with the world-class care for which we are known. The Care Management team is our latest group of “unsung heroes” at Lutheran Medical Center and we are proud to recognize their extraordinary work. 

The Care Management team at Lutheran is known as the discharge planners, and one of their most important roles is to “pace the case,” which means they help get patients through their stay in a timely manner. They perform assessments on every patient, screen for Medicare/Medicaid requirements, and handle patients discharged from the Emergency Department, Mom/Baby and all medical floors. They work with each patient to see if they need support and if they will be at risk after they leave the hospital.   

They are transition coordinators, nurses and social workers. Each member of the team provides the same services while applying their own practice knowledge and experience. Together they reflect one of the most seasoned and successful teams in the Denver Metro area. 

Care Management is wholistic. Services include planning for outpatient condition management and follow up care as well as addressing the larger barriers to maintaining health, the social determinants of health – food, transportation, mental health services, and resources. This is sometimes an overlooked area of healthcare. In order to prevent a lapse in care that is focused solely on physical symptoms and treatment, Care Management steps in to provide the additional layer of support and resources for patients in need. 

“We don’t care for cases, we care for people,” said Leta Gill-Scott, Manager of Care Management at Lutheran. “I love Lutheran’s atmosphere and culture. I’ve never worked with a more dedicated group of caregivers who are committed to doing the best for our patients every single day. They truly walk the walk and are unbelievably engaged with each other, our patients and our community.” 

Care Management provides what is known as transitions of care, which includes creating a safe discharge plan for a patient to leave the hospital. This can mean placing people in skilled nursing facilities, shelters and temporary housing, senior centers, home health, or returning them to the care of a loved one. They also help patients’ families create a new plan when they can no longer care for the patient in their home.  

Their main goal is to make transitions out of the hospital a success. When it comes to our older patients, they work with the Lutheran Foundation, that supports a senior resource center. They fund a program called “A Perfect Homecoming,” which is designed to help seniors stay in their homes. The program can provide assistance with food, medications, and transportation through either a 60- or 90-day program. 

The Care Management team is comprised of 19 caregivers. Each weekday, there are 10 caregivers on staff and each of them works with approximately 20 patients a day. On the weekends, there are four caregivers who work with approximately 60 patients each day.  

The team receives grants and works with community partners, like Food Bank of the Rockies, to help those facing food insecurity. The Food Bank provides a weekly emergency food box for an entire year to patients in need. 

The Care Management team also works with free clinics to help patients establish a primary care provider. “Everyone should have someone to follow up with when they leave the hospital,” said Leta. The goal is to have a safe and healthy environment for patients who are discharged, and to keep them from having to return to the hospital.   

“We are very lucky to have four case management coordinators here at Lutheran who manage our entire home health care and referral process,” said Leta. “You don’t see that in other places. Everyone on my team is invested in learning clinical knowledge in order to excel at their jobs. That’s not common for social workers since it’s not typically in their arena, but our social workers do it. In turn, our nurses are invested in learning the social work side of things. Everyone is willing to jump in and help out wherever they’re needed to support each other.” 

A patient’s quality of life can be improved and sustained when you have people there to make sure they get the services they need, and this team is committed to doing just that. Care Managment is a cornerstone to our entire healthcare system. It increases efficiency, reduces unnecessary hospital visits, and helps people live their healthiest lives with successful outcomes. 

“I am in awe on a daily basis of the creativity of my team,” Leta said. “Whether it is producing solutions to reduce length of stay or creating out of the box solutions to an issue with a patient that seems impossible to solve, they do it. They do not settle for giving our patients any less than 100 percent.” 

We sometimes forget that the amazing work that our clinical teams do would not be possible without all the hardworking and dedicated behind-the-scenes team members here at Lutheran Medical Center. Thank you to these extraordinary people working in extraordinary times. You are heroes and we are grateful for all that you do!