NurseCareManagers

   Yolanda is a 68-year-old female with diabetes

   Sondra is a 66-year-old female with diabetes

  Kathy is a 63-year-old female with congestive heart failure, diabetes, and hypertension

1.  Sondra is a 66-year-old female with diabetes.

  • Initial Care Call (9/2/03):  During the contact, Sondra stated she is taking a water pill but had never been informed of having CHF. In addition to sending Diabetes patient education materials, The Care Coordinator sent CHF patient education materials.
  • First Care Follow-up Call (1/5/04):  During the second contact, Sondra stated she keeps forgetting to make a doctor’s appointment. She does not have a blood glucose meter and needs to talk with the doctor about prescribing one. She stated she gets busy and forgets to call. With the combination of the callscript and thediligence of the Care Coordinator, the member was guided in writing down questions for the doctor. The Care Coordinator reinforced the need to call the doctor.
  • Member Incoming Call (1/21/04):  Sondra called to tell us that she had gone to the doctor and had received a blood glucose meter. Her blood sugars were high, but she was comfortable with using the meter. Based on the conversation, the Care Coordinator and member agreed that the member could use additional information about diet.  Those patient education materials were mailed to the member.

 More information will be added as member progresses through the program.

2. Yolanda is a 68-year-old female with diabetes:

  • Initial Care Call (12/30/03):  Upon reaching the member, it was determined that the member could not speak English very well.  She gave permission for her adult son to talk with the Care Coordinator and complete the call. This son keeps a log of his mother’s medical information and puts together her medications. Based on the conversation, the Care Coordinator and the son agreed on selected diabetes patient education materials which were selected for mailing to the member. Upon completion of the initial care call, the son expressed his appreciation for the assistance his mother received from the Medicaid Select program and for all of the information being sent from the Indiana Chronic Disease Management Program. He gave the Care Coordinator his name and phone number as the contact information for this member.

 More information will be added as member progresses through the program.

3. Kathy is a 63-year-old female with congestive heart failure, diabetes, and hypertension:

  • Incoming Call (07-21-2006):  Kathy indicated she had not been out of the house for over a year.  She had very little food in the house and could not get up to reach everything to cook for herself.  She had been sleeping on the couch because she could not get in and out of bed. Family members did not live close enough to help her, and she thought they were fed up with her.  Kathy reported having panic attacks daily and was crying during the call.  Reported having thoughts of suicide, but tries not to think that way.  Care Coordinator requested assistance from the ICDMP Call Center Nurse, who called Kathy back immediately.
  • Call Center Nurse (07-21-2006):  The CC Nurse quickly determined that Kathy was overwhelmed by her situation.  She requested that Kathy go to the hospital, but Kathy was not yet ready, as she had been unable to bathe properly for some time.  The CC Nurse discussed the benefits, both physical and mental, that could be gain by going.  Kathy agreed to get ready over the weekend and go on Monday morning.  The nurse told her she would call her Monday morning to start the process of getting an ambulance.  CC Nurse then contacted the nurse at Kathy’s doctor’s office.  The doctor agreed to directly admit Kathy so that she would not have to wait in the emergency room.
  • Call Center Nurse (07-24-2006):  The CC nurse called Kathy, who was ready to go to the hospital.  CC nurse waited on the phone while Kathy unlocked her front door so the medics could get in.  CC nurse discussed that someone would call Kathy back to let her know the ambulance was on the way.  CC nurse then called the doctor’s office to arrange for the direct admit.  CC nurse called the ambulance and arranged for their arrival at Kathy’s door.
  • Scheduled Follow Up Call (11-06-2006):  Care Coordinator was pleased to be informed by Kathy that her situation has completely turned around 100%.  Kathy wanted to thank the Care Coordinator and Call Center Nurse for ‘saving’ her life.  Kathy said she is now doing most daily chores on her own.  Kathy had helpful services after her hospitalization.  She moved to a wheelchair-accessible apartment, has a scooter, is exercising every day and is now able to walk a little.  She has been faithfully taking her medicines as scheduled and sees her doctor regularly.  Kathy had Meals on Wheels for the first two months, but has been able to cancel their services since she can manage on her own.


 The ICDMP will continue to contact Kathy periodically to make sure her health needs are being met.