MCMC’s efforts to reach out and assist patients between their provider visits are paying off in many healthy ways.
Dawn Weaver was struggling. Several life-altering events had hit her hard the previous few years, starting with her husband’s death from cancer. Only two years later, her father died.
She was suffering emotionally, and her health had deteriorated to such an extent that she lost her job. Then she lost her mother.
“It wasn’t the best six years,” says the Goldendale resident.
Weaver had been seeing her primary care provider, physician assistant Ben Pate, about her diabetes, which she hadn’t been managing well.
When he referred her to the clinic’s care manager, Pamela Ackerman, R.N., she began to see light at the end of her tunnel. Today she can’t even see the darkness in her rearview mirror.
“I have a purpose for getting up in the morning now,” she says.
Ackerman is one of several members of MCMC’s care manager team, which was developed as part of national health care reform efforts to improve patient care. The care managers work with providers in each of MCMC’s clinics, complementing and extending their care by working with patients who have been identified as potentially needing additional attention and services outside their practitioner’s office.
“Care managers focus on what happens with patients between their visits to their provider,” Ackerman says. “There is only so much a provider can do during a 20-minute office visit, and good health outcomes were often dependent on everything going exactly as the provider planned after each visit.”
The problem was all too often patients face obstacles or challenges that prevent them from following their providers’ advice or instructions. The goal of care managers is to connect with those patients most likely to face such challenges and help overcome them. Now, when MCMC providers identify patients who could benefit from follow-up communication or assistance, they alert their care manager, who connects with the individual, assesses his or needs and provides any guidance or assistance necessary.
“We learned a lot when we first started calling patients,” says care manager Amy Hansen, R.N. “We’d call a patient whose physician had prescribed medications and learn she wasn’t taking them because her insurance didn’t cover the cost and she couldn’t afford to pay herself. Another patient wouldn’t be taking his meds because he didn’t like the side effects.”
In instances such as this, care managers will help the patient access resources for financial assistance or work with their provider to find a medication the patient can better tolerate.
Sometimes, it’s a matter of a patient not having the transportation to get to a pharmacy. That’s’ when community health worker Daniel Price steps in, helping find transportation for the patient or identify other community resources as needed.
Price and care manager Brandi Wahler, R.N., remember one patient whose life changed dramatically simply because they were able to provide highly personalized attention and connect her with resources that empowered her to make her own lifestyle changes.
“She had had frequent hospitalizations due to complications from edema, and after her latest one she was unable to walk,” Wahler remembers. “We contacted her and she said, ‘I have to change.’”
With the patient’s own determination, and the care manager team’s help with diet and other health education, she not only got back on her feet, but also lost 100 pounds.
She had lived in a basement apartment with no windows and had struggled with depression, until Price worked with the Center for Living to find alternative housing.
“She now has a window, and the last time we spoke she told me she was drunk on sunshine,” Wahler says.
“People tend to make excuses if the road isn’t well paved ahead of them,” Price says. “Sometimes just clearing some obstacles makes all the difference in the world.”
While most of their patients are referred by providers, the team also tries to identify other patients who might benefit from the personal health advocacy the care managers provide.
“When the program started, we identified at-risk patients by looking for people who frequented the emergency room for non-emergent conditions or who were living with multiple chronic diseases,” says Mark England, R.N., outpatient quality assurance coordinator. ”Insurance companies also have identified patients who use a lot of health resources and may benefit from more attention.”
He adds that patients hospitalized with heart failure and lung disease (COPD) are automatically followed by a care manager,working with their physician or provider,weekly for one month.
But that frequency of contact isn’t always needed. “Sometimes all a patient needs is a call or two just to get over the hump,” says care manager Andi Wimmers, R.N. “Our goal is to give them the assistance they need to be able to just focus on their own health.”
Dawn Weaver is happy to attest to the effectiveness of the program. With the help of her physician assistant and Ackerman, she has made dramatic strides in the self-management of her diabetes.
A few months ago, her A1C count (a measure of average blood glucose) was 15.1, an indicator of significantly uncontrolled diabetes. Her most recent score was 6.6, “which,” she says proudly, “is good.”
Ackerman would call Weaver to check her progress on controlling her blood sugar level, watching her diet and increase her activity level. “I even went through (MCMC’s) diabetes education program which helped me be more aware of how to live with diabetes,” she says.
The guidance of her physician assistant and the ongoing attention of her care manager have made all the difference in the world to Weaver.
“With their help and persistence, I’ve continued trying to do what was right to have a better life,” she says. “I’m feeling better than I have in a long time.”
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