In September 2015, we enrolled a 70-year-old patient in our Pathways program. He was suffering from an array of chronic conditions, including asthma, diabetes, COPD, pneumonia, and dementia, which led to multiple falls and ER visits. As you can imagine, he required supervision 24 hours a day. Diane, the MD Value Care health coach assigned to the patient’s case, immediately worked to resolve his medication discrepancies by discussing them with his primary care physician. Our licensed social worker, Linda, assisted the patient in applying for respite care from the Alzheimer’s Association, walked him through the process of applying for Medicaid, and even coordinated with an organization to have a wheelchair ramp built at the patient’s residence. I am proud to share that after five months of getting the support he needed in the Pathways program, the patient has graduated and is now visiting the Program of All-inclusive Care for the Elderly (PACE) four days a week. He has also been approved to receive Medicaid personal care. Both the patient and his family are grateful for the great improvements to his health and well-being that the Pathways program has helped him achieve.

Read more about the Pathways program and our other Care Coordination Programs.

This is a case that really exemplifies how the MD Value Care (MDVC) interdisciplinary care team works together to take a holistic approach in supporting patients with complex needs. A 60-year-old patient who was suffering from diabetes, coronary artery disease, and obesity was enrolled in our Engage program in August 2014. A variety of financial and other barriers kept her from routinely checking her blood sugar, and her HbA1c was 13.5% as a result. Fortunately, our licensed social worker, Linda, helped the patient avoid a potentially life-threatening episode by referring her to a variety of resources, including Medicare Part D plans and options, pharmacy assistance programs, and Walmart for low cost medications. Diane, the MDVC health coach assigned to the patient’s case, provided education on diabetes, including how to monitor blood sugar, how to correctly adjust insulin doses, and how to make lifestyle and behavioral changes, as well as worked with the patient to create an achievable action plan. Our registered dietitian, Keisha, helped the patient understand the importance of counting carbohydrates and eating regular meals and snacks to maintain a healthy blood sugar level. By December 2014, just four months after being enrolled in Engage, the patient was using her insulin correctly, having better sleep, and no longer experiencing blurred vision. One month later, she had lost over fifteen pounds, was eating three meals a day with appropriate snacks, and exercising on a daily basis. Her HbA1c had decreased to 8.9%, and she enrolled in a Medicare Part D plan. In talking with Diane, the patient expressed pride in her ability to become engaged in her well-being.

Read more about the Engage program and our other Care Coordination Programs.

About the Author: Karen Smith is a Registered Nurse with extensive clinical experience in Emergency Nursing. Prior to coming to Envera Health 4 years ago, she moved into a non-clinical role in utilization and case management for a large payer group.  Karen is currently the Operations Manager of the Care Coordination team at Envera.  In her free time, she enjoys antiquing and anything DIY.