Care Managers Help Patients Avoid Costly Crises

Medical homes emphasize prevention, early intervention and tight partnership with patients to keep atop chronic conditions. Below, one local woman recounts how she and her care manager teamed up to head off hospitalizations.

Emergency roomStephanie Casey is a juggler. The 63-year-old Henrietta resident, a retired lunchroom monitor, lives with her daughter and helps rear three grandkids (one preschooler, two teens). Against the backdrop of this sometimes-hectic home life, she must be vigilant about keeping health challenges – she’s been diagnosed with hypertension, thyroid imbalance and celiac disease – in check.

“Over the past several years, I’d been hospitalized more times than you can count on your fingers,” Casey said.

Twice, her blood pressure plummeted, bringing her kidneys to the brink of failure. She also suffered a serious reaction to one of her thyroid medications. Last spring, her heart nearly gave out.

Eager to help Casey avoid ED visits, hospital stays, and reclaim her health after a particularly rocky patch (she’d been hospitalized several times over the prior twelve months), the team at Calkins Creek Family Medicine arranged for standing visits. These regular appointments would allow Casey’s newly assigned care manager, Dawn Ange, to keep close watch on her blood pressure and thyroid levels.

One of the biggest challenges was managing Casey’s medications. Since prescribed dosages would fluctuate, keeping track of what to take, and how often, had become confusing, Casey said. To help, Ange actually administered the drugs to her in the office – daily – for a three month stretch. While in, she’d also check Casey’s blood pressure.

“The visits literally took a few minutes,” Ange said. “And for those months that we met daily, Stephanie’s blood pressure and thyroid numbers absolutely normalized. She didn’t require crisis-care interventions once. It was proof to us that pooling our efforts could really work.”

“They do a great job watching over me,” Casey agreed, referring to Ange and primary care physician Michael Obrecht, D.O. “They partner with each other, and with me, so it really feels like a home. I’m not just a number.”

Though the two no longer meet daily – Casey is back to self-managing medications at home, and a weekly visit from Visiting Nurse Service’s Jennifer Cicoria helps feed vital information back into Obrecht’s team – she says Ange still makes regular check-in calls. These might include discussing routine lab work, or even asking about Casey’s kids and grandkids. The relationship is professional and natural at the same time – not unlike a friend touching base.

“I can be honest with them, because they respect me. They even goad me when I need it,” she laughed.

Done right, care manager relationships can spell savings. Mere minutes spent with high-risk patients ultimately could help networks (or accountable care organizations) avoid spending thousands of dollars on needless inpatient stays.

“I absolutely love being a care manager here,” Ange says. “I get to problem-solve, to figure out what works for each individual and help them become the healthiest version of themselves. It’s a lot of care coordinating, but it’s changing lives, like Stephanie’s. It’s incredibly gratifying.”

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