Navigating the healthcare space with a chronic illness can be challenging. It’s completely normal to feel overwhelmed by the chaos of managing medications, your diet, exercise routine, and multiple specialist and doctor appointments. You should not have to be worried about potential gaps in your care on top of everything else. That’s where care coordination can help.
Someone Who Cares About Your Health
“ACN’s care coordination team is a group of nurses, navigators and social workers that collaborate with the patient and their doctors with the goal to close gaps in care and improve the patient’s health. We advocate for patients and educate them to empower people to understand and navigate the medical system,” says Lesley Greven, a registered nurse at Arizona Care Network (ACN)
Lesley recently changed a patient’s life by educating him on managing his type 2 diabetes and hyperlipidemia. Type 2 diabetes develops because the body is not using insulin properly, therefore effecting the metabolism of glucose (sugar) in the body. Hyperlipidemia occurs when a patient has too much fat in their blood, resulting in a heightened risk for heart complications, including heart attack and stroke.
Identifying Problems and Providing Resources
“The patient had an elevated A1c of 12.5 and he did not understand the significance of his level,” Lesley said, “Elevated A1c can lead to slow wound healing (requiring amputation in some instances), neuropathy, changes in vision, risk for glaucoma, and kidney disease that could lead to kidney failure.”
During the patient’s visit, Lesley talked with the patient about these effects of elevated A1c and about how diet and exercise could help him decrease his weight, which can also decrease A1c and cholesterol.
Lesley reviewed the patient’s lab results and taught him how to understand lab values and set realistic goals by understanding which decreased values to strive for.
“When reviewing his medications, I realized he was taking two Actos medications; a 15mg and 30mg,” Lesley said, “His primary care provider (PCP) had increased his Actos from 15mg to 30mg at a previous visit, but the patient didn’t understand that he should stop taking the 15mg dosage, so he was taking 45mg total – far too much — as a result.”
Taking any medication at a dose that is higher than prescribed can lead to complications ranging from negative effects on the chronic illness the medication is intended to treat, to side effects in the patient’s body. Lesley went over the patient’s medications with him to ensure he is taking the correct dosage of each one and confirmed with his doctor that he should stop taking the 15mg Actos.
After their visit, Lesley mailed the patient useful materials on his diet and followed up with a phone call to go over the materials.
Open Communication Among Healthcare Providers
Lesley also followed up with his primary care physician to ensure the medication confusion and update was noted in the patient’s record and recommended a referral to a nutritionist. The PCP agreed.
Open communication among the entire care team gives patients more coordinated care and a less frustrating healthcare experience. When the patient goes back to his PCP, he will not have to explain why he stopped taking the 15mg Actos. The PCP is already up-to-date on the patient’s healthcare, which reduces confusion.
Taking Strides Toward Improved Health
Lesley continues to follow up with this patient because of the collaborative relationship they developed in managing his diabetes to improve his overall health.
“The patient has developed healthy lifestyle habits including exercise, eating smaller portions, and eating fewer carbohydrates and fats,” Lesley said, “His energy has improved immensely.”
Interested in learning more or seeing if you are eligible for Care Coordination? Contact ACN’s concierge at members@azcarenetwork.org.
