Saint Francis Health Care Partners

Population Health Management: Patient Success Stories

Empowering Patients to Manage Their Health
Jessica ORourke, a Community Healthcare Coach, received a referral to outreach a patient who had just been discharged from the Emergency Department.  The patient’s medical history was complex, she was being followed by multiple providers and her chronic illnesses were not well controlled.  Prior to meeting Jessica, the patient had been seen in the ED 14 times within a six month period.

Jessica assisted the patient to coordinate care among her many physicians, provided education on how to navigate the healthcare system, and provided education on medication and symptom management.  Throughout Jessica’s outreach, she was able to attend medical appointments at the community health clinic with the patient which helped to establish integrated care for her medical and mental health needs. To date, the patient has been able to manage her medications independently and has significantly decreased her ED utilization to just four encounters in four months. Jessica continues to check in with the patient on a monthly basis.

Patient Advocacy to Improve Health Outcomes
Ms. H was discharged from the Emergency Department and several days later, received an outreach letter from Jessica ORourke, her Community Healthcare Coach.  She decided to call Jessica in search of help.

Ms. H explained her concern: she was seen in the Emergency Department for treatment of bronchitis and was prescribed a medication that wasn’t covered by her insurance. Because she was unable to afford the medication, she thought that she should return to the ED because she continued to experience the same symptoms. Advocating on Ms. H’s behalf, Jessica contacted her PCP to request that an alternate medication covered by her insurance be ordered.  The PCP wrote a new prescription and called it into the patient’s pharmacy. The medication was delivered to Ms. H’s home later that day and she took her first dose. Through Jessica’s intervention, an unnecessary ED encounter was averted. Jessica provided Ms. H with support and education about the importance of maintaining medical follow-up appointments with her physician.  As a result, Ms. H has continued to seek care at  her physician’s office rather than in the ED.

Using Creativity to Meet Patient Needs
Sherry Leary, a Community Healthcare Coach received a referral from a primary care provider requesting care coordination services for a medically complex patient.  The patient had been recently discharged from the hospital following 23 ED visits and 12 inpatient admissions during the previous six month period. The patient had a 24-hour caregiver, home care and visiting nurse services, but no family. 

Sherry reached out to the patient; spoke with her weekly and within a month, the patient was agreeable to a home visit by Sherry and Julie Wanamaker, a team Social Work Navigator.  In collaboration with the patient, provider, 24-hour caregiver, and homecare agency, Sherry and Julie came up with a creative plan to address the identified issues.  The primary goals were to  support the patient to maintain as much independence and decision making as possible while keeping her  healthy at home. 

In-home services were increased including a weekly visit from the provider and social worker.  But the patient’s best-loved new service has been the weekly visits from Polly, the therapy dog.  The patient looks forward to visits with her new friend and has not returned to the hospital for nearly a month.

 Restoring Healthcare Coverage
On September 10th, Krista Berardy, a Community Healthcare Coach, reached out to Mrs. B, a patient who had just been discharged from the ED.  An elderly woman in fair health with several chronic health conditions, Mrs. B lives alone and manages her healthcare needs with little additional support. During the call, the Coach learned that Mrs. B’s Medicare coverage had somehow been dropped. This was a major concern because without insurance coverage, Mrs. B would be unable to afford the cost of her medications and follow-up appointments. Krista reached out to the Medicare office and worked with Mrs. B to get her coverage restored during the month that followed.  Finally, after receiving conflicting information between Medicare and the Social Security Administration, Krista contacted a Medicare advocate to enlist additional support.  The advocate’s involvement was integral in restoring Mrs. B’s Medicare coverage within a week.  Krista and Julie Wanamaker, LCSW continue to support Mrs. B on a weekly basis through telephone outreach and home visits.