Clinical outreach nurse educates needy patients about community resources

By Cindy Atoji Keene

Controlling healthcare spending continues to be an ailment with no cure in sight. Massachusetts boasts that almost 98 percent of its residents have health insurance coverage, but that doesn’t reveal the whole picture of rising costs, especially for poor and disenfranchised people throughout the state. Clinical outreach worker Ann Mutharia hears the stories all the time: the man with diabetes who couldn’t afford his co-payment and had stopped taking his insulin; the deaf man who needed medical attention as well as food stamps and fuel assistance but wasn’t able to get through to overwhelmed social service agencies. Mutharia, 36, who is a licensed practical nurse, is part of a non-profit health plan’s pilot program to prevent often-isolated members from developing chronic conditions by connecting them with vital healthcare services. “The idea is to help members get the right care, at the right time, from the right person,” said Mutharia of Medford-based Network Health, who makes phone calls and house visits to make sure they are getting all the services, benefits and support they need.

Mutharia and others on the Network Health clinical outreach team reach out to over 500 patients a month, identifying those who are most likely to develop chronic and high-cost conditions through a predictive modeling process that examines the risk factors of people who are not currently receiving preventative care services. These “high-risk” members can often be difficult to connect with –¬ some of them don’t speak English very well; others are transient or don’t have even have a working phone.


Q: How do you connect with vulnerable people in the community?
A: I’m the nurse for the Worcester County area, and every month I get a list of Network Health patients who have complicated or severe illnesses, such as asthma or lung disease, heart disease, or some neurological conditions. I talk to 30-40 patients a day, with the goal of trying to educate members on what resources are available for them. I get all sorts of questions, and not just about healthcare: How do I find a lawyer? Where do I go to apply for social security disability? As just one example, the other day I spoke to a woman who confessed that she was having trouble controlling her drinking, but didn’t want any help. I called her again a few weeks later, and she was desperate for assistance. I contacted an emergency rehab, and she was admitted the next morning.

Q: What are some of the biggest challenges you face?
A: Often, when talking to recent immigrants, I need to overcome cultural differences and language barriers. It helps that I am multi-lingual – I’m from Kenya and speak English, Swahili, and know bits of some other languages. It’s important to understand the cultural context of some patients. For example, while Americans will look you straight in the eye, for others, this is a sign of disrespect. I need to be open and sensitive to different backgrounds and needs.

Q: How do you empower patients to take control of their health?
A: Patient education is a large part of what I do, and often doctors are too busy to follow-up to make sure treatments regimens are being followed. One patient was given diabetes literature but it turned out he didn’t know how to read, so he was clueless about medication side effects or proper diet and exercise. I try to make sure that patients understand about issues that impact their health, because that gives them a sense of responsibility and independence.


Q: Are you surprised about how many needy patients there are out there?
A: I’m taken aback every day. I can’t believe the hardship and struggles people face. Every day I speak with someone who doesn’t have a job; not enough food, or can’t even afford diapers for their child. There are a lot of problems out there, right in our own backyards.

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