Stories
Rather than tell the stories that are shaping our work, we decided to let those involved tell their stories in their own words. The truth of the matter is that this story is just beginning. It is also true that you may have a chapter to write or a piece to contribute. Please contact us, and let’s begin the conversation.
How Our Model Impacts Homecare Patients
“During our team meeting/case conference the pharmacist reviewed the medication list of a patient and discovered she was on two drugs of the same class. After a phone call to the physician, the patient was able to stop taking one of these medications. She was thrilled that she was able to save $130.00 per month as a result!”
Nurse Case Manager
“I recently saw a heart-transplant patient – who is also diabetic - on a daily basis. A telehealth monitor was installed that transmitted vital signs twice daily to our office. This enabled our telehealth nurse to detect a needed change in medication, which she was able to coordinate with the physician and prevent a rehospitalization. Each day I covered a different topic with the patient to educate and empower her. She stated her goal was to get her strength back, and worked toward that objective. I watched as the patient was transformed from very anxious to very confident that she could manage her condition.”
Nurse Case Manager
“I saw the impact of this model with a patient and their family when I asked the patient to set her own goals for managing her condition. She said her goal would be that her children would learn about her disease. They were present and heard her say this, and they were willing to learn. Amazingly, as the patient watched her family learn more about diabetes, she became more motivated to learn herself. Their desire to learn actually motivated her to learn! When we added the telehealth unit, and could show her the impact her diet had on her blood glucose reading, she was able to ‘connect the dots’ for the first time. The change in her life has been phenomenal!”
Nurse Case Manager
“A big change in this model is the approach with which visits are made. With the theory-based self-management support we leave behind the paradigm of health professionals as figures of authority who must be obeyed. The home health nurse becomes a coach. The patient is seen as the captain of the team. The coach comes with tools to assist the patient in identifying barriers, setting priorities and increasing confidence levels by problem-solving, action-planning and decision-making. Self-efficacy is thereby improved and lives are changed. A good example would be the retired Marine medic who had had his last toe on his right foot amputated. He had been diabetic for more than 10 years. He initially misled us to believe he was using his coagulation meter regularly and was following an appropriate diet. Our presence in the home revealed otherwise. However, because of his Marine training, he was willing to ‘take charge’ when given the opportunity. He accepted the challenge to take control of his health. His wound healed, which avoided the amputation of his foot. He changed his diet, controlled his blood sugars and is now enjoying gardening again. This amazing turnaround occurred in less than one month.”
Nurse Case Manager
“We thought at first the heavy emphasis on technology might intimidate some of our patients. However, just the opposite has occurred: most patients welcome and embrace it. I particularly recall a patient who was assisting us as we tested Telerehab - the provision of therapy visits via two-way interactive video links. Each improvement we made during the pilot resulted in greater participation by the patient in her treatment. Rather than being turned off by the use of technology, she was motivated and empowered to fully engage in her plan of care.”
Therapist
How the Model Impacts Staff Providing Care
“My practice as a nurse has improved since this model was implemented. I learn from each encounter with one of the Clinical Nurse Specialists. I see how the technology helps patients understand their disease and how to manage it. I am thrilled as I watch patients’ behavior change when they better understand what causes exacerbations and show them how self-management is an achievable goal. There is no doubt I am a better nurse because I work in this environment every day.”
Nurse Case Manager
“The utilization of technology is a key component of this model. I am finding this emphasis keeps our staff fresh as they approach patient care in new ways. It is exciting for me to hear their discussions of creative methods to improve patient care through the use of the technology we have available and the support we enjoy from our IT department. Everyone has a ‘let’s try it and see if it works’ mentality, rather than the typical “we’ve never done it that way before” mindset.
The model has also challenged our therapists to look beyond traditional candidates for therapy in ways I did not anticipate. For example, in the past we typically saw post-surgical orthopedic patients and focused solely on therapy to the affected area of the body. With the implementation of the model, we now think more broadly. We consider the impact of the chronic condition on needs we could address in therapy, and conversely how therapy could improve their self-management skills of their disease. For instance, we know a diabetic patient is more likely to fall, and we now proactively address that possibility in the care we provide.”
Therapy Supervisor
What Others Are Saying About Our Model
“This model extends the influence of the physician and reinforces his plan of care in an exciting and innovative manner. My desire is to see their program disseminated on a larger scale to enable more of our medical systems to benefit from their experiences. From what I have observed, this program can and should be repeated throughout the nation. It is simple in its design, even to the point that you ask yourself, “Why hasn’t someone thought of this before?”
Physician
“I have seen this model in action at their facility. I believe it has the potential to serve as a framework for chronic care reform. Model adoption by home health agencies nationwide can potentially improve the care of an untold number of patients in need of assistance with disease management.”
United States Senator
“Besides their innovative use of telehealth technology, I would also like to emphasize their program’s success is also due to their seamless incorporation of the program into the agency’s workflow and the successful attainment of buy-in and support from their staff nurses. Both of these are common barriers to telehealth program success, and by avoiding them they have shown their commitment to the comprehensive care that telehealth allows them to provide.”
Telehealth Vendor
How Model Is Being Applied In the Marketplace:
Success Stories from the Employees of a Self-insured Employer’s Chronic Care Benefit (Provided by 2020 Health Solutions)
- A diabetic client was not checking blood glucose levels at all, in spite of her physician’s instructions to do so. However, she is doing so twice a day since enrollment in the program.
- A coronary artery disease client had been prescribed Plavix, but since he could not afford the drug, he stopped taking it. His Health Partner arranged for the patient to get samples from the physician’s office, and put him in touch with a company to receive a regular supply at a reduced rate.
- A client desiring weight loss set a goal to check into a weight loss program, but subsequently decided it was too expensive. However, she decided to pursue weight loss on her own and set a goal of eliminating a favorite food item from her diet for one week. As a result, she had already lost weight and is ready to set the next goal.
- After meeting with her Health Partner, a client decided to set her blood glucose goal as 160 – rather than the recommended 180 – to more tightly control her diabetes.
- A client’s blood sugars were bottoming out at night (in the 40s – 50s range), not eating regularly, and not managing her diet. After enrolling in the program and meeting with her Health Partner, she is now eating appropriately, enjoying controlled blood sugars, and is actively engaged in her self-management by seeking additional guidance and advice.
- A client’s blood sugars were running in the 200s at the time of enrollment. Her immediate goal was to begin exercising regularly, and she is now doing so daily. Her latest blood sugar reading is 97 – the lowest it has been in a long time and she is thrilled.