Here at Aledade, we talk a lot about getting out beyond the four walls of the practice – because that’s how you get a window into the real challenges that a patient faces every day. They might be challenges we couldn’t have seen if we kept doing business the same old way. And sometimes, if we fix those, everything else can fall into place.

One of our partner practices proved this not too long ago. Dr. Syed Zaidi has been working in the town of Ripley, Tennessee for the past 20 years – providing care to the families around Ripley through his independent practice. And thanks to Aledade, he was able to care for them with some new tools.

In 2016, Dr. Zaidi started offering Chronic Care Management to some of his Medicare patients. This meant that a care management team would check up on his patients with more complex chronic conditions, making sure they had their medications and to try to get ahead of anything that could go wrong.

One patient had been in care management for a while, but Dr. Zaidi and his team weren’t seeing any changes. Neither he nor the patient felt like they were really making progress.

Then one day, the family opened up, and shared the real challenge they were living with every day. They were homeless. For several weeks, the entire family had been living out of their car – joined by a few animals they had adopted as pets. Their home had been infected with mold, making it uninhabitable, and they didn’t know where to turn.

That’s where the care management team and Dr. Zaidi’s whole practice jumped in. They helped the family find a safe place to live. Through community resources, they secured donations and raised money to provide the family everything from new mattresses to new clothes. And, since the family’s new home couldn’t take pets, Dr. Zaidi’s team even found good homes for every one of the animals. Today, the family’s healthier, and the patient’s chronic conditions are under much better control.

Chronic diseases are only going to get more challenging in the years to come. In 2012, the CDC estimated that one out of every two adults in the U.S. had at least one chronic condition. One in every four U.S. adults had two or more. And 86 percent of all of U.S. health care spending in 2010 was for people with at least one chronic medical condition. Chronic care management – by actually connecting patients with an active and engaged care management team – can tackle a daunting challenge for our health care system, and open up new possibilities in lowering costs.

But most of all, CCM helps our patients live better lives. Thanks to CCM through Aledade, we found out about this family’s situation. And thanks to the compassion and drive of Dr. Zaidi and his care management team, this family got back on their feet and back on the road to better health.