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02.05.2019

Care Management On Call: How One Care Manager Went Above and Beyond for a Patient

by Tara Bravo, Care Manager

As a care manager, I’m a patient advocate and the first line of defense for keeping high risk patients healthy. My regular calls help build a trusting relationship with these patients so that I can help them control their chronic conditions and prevent any new issues from becoming serious. During my monthly calls with patients, I quickly assess their health concerns and start evidence-based protocols to divert avoidable emergency room visits or unnecessary hospital admissions until they can be seen by their provider. Beyond that, I get to connect with individual patients in a personal way to help them along each step of their health journey.

What follows is a story about the power of these relationships. It’s a story about how I was able to help a patient get through a high-risk situation, in the middle of the ocean, because of the trusting relationship we’d built over time.

Recently, one of my care management patients began experiencing symptoms related to his heart failure while on a cruise ship in the Bahamas – a cruise he was advised not to go on by his cardiologist. Throughout the day the patient had been experiencing dizziness and shortness of breath. During dinner on the formal night of the cruise his symptoms worsened. In a panic, he and his wife called me from the next port.

Building Trust

I wasn’t always the patient’s first call for any healthcare concern. I had been working with this patient since I started at this practice eleven months ago, and it took us time to establish our rapport. We enrolled him in our care management program and began a monthly call to discuss how he was doing and talked through his challenges that could negatively impact his health. When I first met with him his wife was on a month-long visit with their grandkids. One day he came to the office and, very upset, he explained he could not afford his medications and that he was all alone at home. I worked with his primary care physician (PCP) to switch his insulin to a less expensive brand and told him to call me anytime, not to hesitate, and reinforced that I’m here to help him in any way that I can. During these initial conversations about his care, he thanked me over and over again for listening to him and helping him make good decisions about his health. That’s when I knew we were making a connection.

Staying Connected

Three months later, I noticed during our monthly call that he sounded a little off. I called his wife to make sure everything was ok and that’s when she told me what was going on. He was not taking his medications correctly, sometimes forgetting a dose and he had started to increase his alcohol consumption. Right away, I made an appointment for him to come to the office so that we could discuss these new concerns with his PCP. Because of my trusting relationship with the patient we were able to have an open and honest conversation with his care team and develop a plan of care to address the impact of his alcohol use.

A Call During Crisis

It was this relationship that enabled me to extend him a lifeline, even from far away. When we connected from the cruise port, the patient and his wife were both scared and nervous and had no idea what to do. I reached out to the provider who recommended diet modifications to the patient and to stay on the ship for the remainder of the time. I also made an appointment for him to see his PCP immediately after he and his wife were back on land and I followed up to make sure he attended that visit.

During that appointment, we addressed ways to help get his health back on track. After following the new plan, his health improved!

Lasting Impact

This story is so impactful because it reminds me that Aledade’s care management program works. With support and training from Aledade, care managers across the country are able to help build relationships that keep patients healthier and out of the hospital. That’s what we’re here for – to help patients, even if they’re stuck on a boat in the middle of the ocean.