Care Coordination
Todd faced ongoing challenges managing his diet , blood sugar testing and daily insulin injections . Poor sleep , a strenuous job working on the roads in Seven Hickory Township , and a high level of emotional stress due to a past trauma also negatively impacted his ability to control his diabetes .
Lydia made sure Todd ate healthfully , but his blood sugar levels continued to seesaw from very low to very high . Already tall and slender , Todd had trouble maintaining his weight of 165 pounds . “ He was wasting away in front of me ,” Lydia said , reflecting on the period of time when Todd weighed only 122 pounds . “ It was frightening because there are so many variables that impact his blood sugar levels , and it was difficult to get a handle on his needs each day ,” she said .
As a result , Todd suffered many side effects ; fatigue , mood swings , frequent urination , dehydration , shaking and depression were among them . And while Todd struggled to enjoy life , his endocrinologist labeled him as ‘ non-compliant ’ on medical records – a term that typically indicates that a patient isn ’ t caring for himself as instructed .
The label made it difficult for Todd to get an insulin pump – a tool both he and Lydia thought could help him regain his health . And while Todd had established great rapport with Family Physician Gregory Deters , MD , at the Family Medical Center , it was the endocrinologist who managed Todd ’ s diabetes care and who needed to approve the pump .
By chance , Todd ran into a former high school classmate and SBL Care Coordination Coach Lori Stults one day when he was at Dr . Deters ’ office . Todd told Stults his dilemma , and she jumped into action . Stults reached out to the care coordination team , including Lisa Carlen , RN , to create a comprehensive care plan that was tailored to meet Todd ’ s healthcare needs and priorities .
Carlen contacted Medtronic , the insulin pump manufacturer , about providing the pump that Todd needed . She learned that Medtronic prefers to work with patients ’ primary care providers over specialists because they tend to have a stronger relationship with patients . This information enabled her to engage Dr . Deters in Todd ’ s care plan in a way he hadn ’ t participated previously . “ Oh my gosh ! Did we do a happy dance that day !” Lydia said .
Carlen hosted a meeting with the Bowlins , Dr . Deters , a Medtronic representative and SBL care coordinators to consider the new treatment option . Within a few days , Todd had his pump !
“ It has literally impacted every aspect of my life for the better ,” Todd said . Since the pump is attached 24 / 7 , Todd can make insulin adjustments by simply pushing a few buttons . And now he has the energy needed to keep up with his two young sons , Jesse , 4 , and Levi , 2 , and his teenage son , James .” In six weeks , he put on 20 pounds and his blood sugar levels have improved dramatically .
“ It all just fell into place ,” Carlen said . “ As care coordinators , we have the luxury of being able to meet with people as much as we need to , to figure out what works best for each individual .”
“ They saved his life . They really did ,” Lydia said . “ We owe them so much because they cared enough to show us that ‘ Yes , you can stand up and fight for this and we ’ re going to fight with you .’”
Care Coordination
Navigating the healthcare system can be difficult for anyone , but it ’ s especially difficult for people with chronic conditions like heart failure , chronic obstructive pulmonary disease ( COPD ) and diabetes .
People with these conditions often need care from numerous doctors , nurses , and other medical professionals in multiple settings of care . They transition between doctors ’ offices , hospitals , nursing homes , home health agencies , and home in order to obtain the services they need . Studies have shown that such transitions can result in incomplete and / or inaccurate transfer of information and coordination of care is key to reducing risk and fostering optimal outcomes .
Sarah Bush Lincoln implemented a Care Coordination program to improve the health and quality of care for these individuals . The care coordination team , which includes nurses in the Emergency Department , works with people in a collaborative process to develop a care plan that reflects the individual ’ s values and priorities .
In July , Sarah Bush Lincoln received $ 565,942 grant from The Office of Rural Health Policy that will target 40 to 60 people with heart failure or COPD and who receive care at Family Medical Center in Mattoon in an effort to keep them well and out of the hospital . The project also aims to improve the resources and skills of the SBL care team .
For more information about care coordination , call SBL Care Coordination Director Carol Ray , RN , at 217-258-2405 .
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