Kevin Wiehrs is a nurse in Savannah, Ga. But instead of giving patients shots or taking blood pressure readings, his job is mostly talking with patients like Susan Johnson.

Johnson, 63, is a retired restaurant cook who receives Medicare and Medicaid. She has diabetes, and has already met with her doctor. Afterward, Wiehrs spends another half-hour with Johnson, talking through her medication, exercise and diet.

"So it sounds like you cut back on your sweets, things that have a lot of sugars in them. What about vegetables, your portions of food?" Wiehrs asks Johnson. "Have you made any changes with that?"

"A little bit," Johnson says. "Ain't gonna lie — a little bit."

Wierhs, 51, was a hospice nurse for 15 years and a social worker before that. Now he is one of five new care coordinators at Memorial Health, a medical system based in Savannah. He was hired to pay special attention to patients with poorly controlled chronic conditions like diabetes and heart disease.

"Some of these patients have fought with their diabetes for many years and get very complacent with the whole situation and feel that, 'No matter what I do, it's not going to make a difference,' " he says. "But it does."

It's hard to persuade people to change, Wiehrs says. And patients are sometimes skeptical about his role in their care. He says they often approach him and say, "I've been coming to this office before; I've seen these physicians. And now you're somebody new. What are you doing, and why do you want to talk to me?"

Getting these patients to trust Wiehrs is an important part of the hospital's strategy for dealing with rising costs. Memorial is investing $500,000 a year in care coordination, in the belief that the program will save money in the long run and improve the quality of care.

Memorial CEO Maggie Gill wants Wiehrs to teach patients to care for themselves.

By improving the management of medical conditions outside the hospital, Gill says, "you can help people prevent crises from happening."

She says Memorial provides about $30 million in free care each year. Because Georgia is not among the states that have chosen to expand Medicaid under the Affordable Care Act, the hospital is going to continue to give a lot of free care to people who have low income and are uninsured, Gill says. On top of that, Medicare is penalizing hospitals (via lower reimbursements) when patients have to be admitted repeatedly for some specific conditions. Gill hopes Wiehrs can prevent some of those repeat visits.

Gill recalls one Memorial care coordinator who helped with a particularly difficult case — another patient with diabetes who tended to show up in the emergency department two or three times a year. Working with the patient's wife until she felt comfortable measuring her spouse's insulin levels, and comfortable delivering insulin, made a big difference.

"They avoided at least two emergency department visits by having that resource," Gill says.

On a typical day, Wiehrs meets with three or four patients and calls people who have just been released from the hospital.

He says patients end up trusting him. He makes sure they're feeling well, taking their medication and that they know when to come in for a follow-up. Wiehrs gives them his direct phone number so they don't have to hassle with the front office. And for those who can't afford their medications, Wiehrs says, he'll call drug companies or do research online to help find discount drug programs.

"Sometimes you have to get creative and you have to spend the extra time to see what might be available," he says. "That's the benefit of me being a care coordinator and having the experience that I have. I know how to navigate the health care system."

Wiehrs says he's encouraged by the results he's seeing already — like the patient who practically bounded into his office recently, breathing easier thanks to new asthma inhalers.

The hope is that lots of little improvements like that will add up to big savings to the health system — and will improve the health of patients.

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