Care Coordination for Chronic Health Conditions

Tom (not his real name) is a 56-year-old LIFEPlan member who lives on his own, enjoying life and community with a great deal of freedom.

 

Recently, Tom became ill and was admitted to the hospital where he was diagnosed with Diabetes.

This new health condition was a challenge for Tom requiring him to make many changes to his lifestyle, from changing eating habits to administering daily self-injections of insulin. To assist Tom with his new healthcare needs, he was admitted to an acute rehab for approximately 3 months for education and training.

Wendy Applebee, Tom’s LIFEPlan Care Manager, has tracked his progress and visited him at his home shortly after he release from rehab care. It wasn’t long before Wendy realized that Tom needed additional help to properly manage his insulin injections. Tom said he was missing a supply of ‘red caps’. Not having a nursing background Wendy wasn’t sure what Tom was referring to, so she contacted her supervisor, the Incident Management Department, and Clinical Support Department for support. Wendy’s concern was that Tom would not be able to stay in his home if he wasn’t able to care for himself.

Wendy and LIFEPlan supervisor Rachel Pomanteer were contacted by Carrie Loubier, LIFEPlan Nurse Education Manager to learn more about Tom’s need. Carrie quickly determined that the red caps Tom was referring to were needles needed for the insulin injections. Working with Tom’s Pharmacist Carrie was able to get a ‘consultation’ to ensure that Tom knew how to correctly administer insulin.

Working together, the Care Management, Incident Review and Clinical teams made sure that Tom had supports in place for his insulin management. With that support in place, Tom was able to remain in the home he cherishes.

Having lunch at a local diner recently, Tom shared his story with friends, and unbeknownst to him one of his friends was a nurse who offered to check in on him daily to help him with his diabetes care.

Thanks to the efforts of Tom’s friend and the LIFEPlan staff who cared for him in this situation, Tom has adjusted to his new medical needs, is doing well, can live independently in his home, and continue enjoying the life he chooses to live.