The Second Time's the Charm
This particular patient has been enrolled with Eastside Health Network Care Manager Monica MacDonald twice now.?The first enrollment did not go well because of his lack of readiness to make necessary lifestyle changes.?This story is about his second enrollment from November 2021 to August 2022.
The patient was a 70-year-old male with type-2 diabetes, hyperlipidemia, hypertension and gout. His Primary Care Provider?(PCP) was excited that Monica was working with him because he needed more support than the PCP could provide in a 20-minute appointment.
The provider reported that her patient was non-compliant with medication and attending provider appointments.?He lacked education about his disease process and had an A1C of 10.2.
During Monica's second enrollment assessment it was evident that this patient was ready to do the work. He was eager to start exercising. His weight was 320 pounds, and he had an active gout flare up. His exercise of choice was a stationary bike, which Monica assisted him in acquiring through Facebook Marketplace.
Before getting started on the bike, the patient received cortisone shots in both knees and religiously took his medication for gout to alleviate pain. Unfortunately, cortisone injections can increase blood sugars. His fasting blood sugar readings were 280-320.?He was behind on all his follow-up doctor’s appointments, including endocrinology.
There was a lot to accomplish in his care plan, so each week Monica would set small goals. His initial goals were to call each provider on his care team and schedule appointments. He scheduled his endocrinology, cardiology, and annual wellness exam with his PCP the first week.?Monica and the patient then made exercise goals of riding his bike daily. He started at 3 minutes and worked his way up to 6 minutes.
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Monica attended his endocrinology appointment with him and was included in establishing a care plan. The patient was started on new medication and a continuous glucose monitor. He also received a referral to diabetes and a nutritionist. Monica made weekly reminder calls for his nutritionist and diabetes education appointments. She also called to assess whether he was taking his medication and scanning his continuous glucose monitor. In these calls, Monica included education on his disease process and information about his medication. All along, Monica maintained open communication with the endocrinologist and PCP.
This second enrollment ended with positive results.
During the patient’s second time in care management,?he lost 18 lbs. He started at 320 and had a discharge weight of 302. His starting A1C was 10.2, and?his discharge A1C was 8.8. He?attended all necessary provider appointments. Now that he is discharged, he continues to attend his appointments and get his lab draws as advised by his care team. He is still striving to achieve more health care goals?under the supervision of a bariatric clinic. He is also considering gastric bypass. The patient called Monica a few weeks ago to tell her how well he is doing. She encouraged him to call anytime he would like to share his successes or challenges.
On a long health care journey, not every step is going to feel like a move toward the positive, but it is all part of the process. Monica made herself available and created a safe space the patient felt comfortable returning to when he was ready to commit to his goals.