When patients don’t know if they can afford life-saving medications next week, how can we expect them to focus on better health next year? When anxiety and sleeplessness lead to late-night food cravings, how likely are they to adopt healthier eating habits? When they're socially isolated, what are the odds that they can overcome depression?
Those were the types of challenges that Evolent RN Care Advisor Jessica Cooper had to confront as she began working with a middle-aged patient who had serious chronic health, social and emotional needs. When Jessica reached out to the patient, the woman had just separated from her husband, a nurse who had been managing her appointments, medications and finances. As a kidney transplant recipient, she didn't know how she was going to afford the expensive drugs needed to prevent organ rejection. She had managed her Type 1 diabetes for decades, but with the recent anxieties in her life increasing stress hormones and overeating behaviors, her blood sugar levels had been elevated to unhealthy levels. Add to that the daily struggles of living with poor hearing and eyesight, with no family nearby, and it was clear that her situation was dire.
This woman's case was particularly memorable for Jessica, who helps patients in southwest Indiana to manage multiple complex diseases.
"I've never had a patient with so many things that we needed to work on that weren’t necessarily medical," Jessica says.
Fortunately, the patient jumped at the opportunity to enroll in care management. Because of the woman's hearing and vision loss, Jessica arranged to meet with her face-to-face in a primary care clinic for their initial two-hour assessment. The teary-eyed patient was overwhelmed but also relieved to get the extra support of care management.
"We started to dig in and prioritize what needed to be taken care of first," Jessica says. "It was very important for her to get those transplant medications. We were filling out applications together, helping her to make calls and fax papers one medication at a time."
They continued meeting in-person every two weeks to discuss her progress, fill out more forms and follow up on applications. Eventually, the drug manufacturers approved her request for financial assistance for four high-cost medications, including the two anti-rejection drugs for her transplanted kidneys. She received approval for Medicare and was awaiting a response from Medicaid.
Then, Jessica took a longer view to help the patient improve her diabetes management. Although the patient had years of experience counting carbohydrates and regularly testing blood sugar levels, she and Jessica had to tackle other root causes—the anxiety and isolation that were taking a toll on her overall health. The patient wasn't sleeping well and would frequently eat too much at night, depriving her of that extended period of fasting she needed to keep her glucose in a normal range overnight.
With Jessica’s encouragement and guidance from a social worker, the woman reconnected with a therapist she had been seeing previously. They spoke with her about the importance of socializing more, and the patient took the initiative to join a divorce support group. Educated on the importance of exercise in maintaining her mental and physical health, she also joined a Pilates class.
Jessica credits the patient for bringing the right attitude to these challenges, taking frequent notes, staying organized and following through on recommendations. Over four months, the patient’s divorce was finalized, and she was visibly happier during the visits. By the time she graduated from care management, she had returned to healthier eating habits and her blood glucose levels had greatly improved.
"The outreach call couldn't have come at a better time," Jessica says.