Day in the Life – MiPCT Management Done Right

May 1, 2013 3:52 pm

Contributed by Stacey Overholt, BSN, RN, and Phil Baty, MD

This Day in the Life actually takes you through a patient’s story over a period of several months to highlight the importance of continued care:

Mr. F. is 88 years old with a history of, diet controlled Diabetes Mellitus, Peripheral Vascular Disease, Low back pain and many other diseases. He lives with his wife at home and he has been independent. In early November 2012, he presented to the Northeast Office, located at 5171 Plainfield with worsening of chronic lower back pain that had not responded well to physical therapy and pain medications. He didn’t tolerate narcotics and his renal insufficiency precluded non-steroidal anti-inflammatory drugs, so he was started on a prednisone taper and referred to a pain specialist.

At this time he was referred to Stacey Overholt, BSN, RN, the MiPCT (Michigan Patient Care Transformation Demonstration) Care Manager for support, care coordination, and symptom assessment.

Overholt has worked at Saint Mary’s for the past five years and has recently moved into this position. She oversees patients who have chronic illnesses, providing disease management support and developing relationships that encourage consistent care and open access. Overholt helps to navigate the health care system for patients as well. Her role fulfills a parameter of Advantage Health offices being Patient Centered Medical Homes.

Over the next few weeks, the patient’s wife called Overholt several times to report symptoms and to“touch base.” In time, Overholt realized that the reports were getting worse, and the patient was experiencing increased fatigue, orthostatic hypotension, weakness, weight loss, anorexia, abdominal pain and decreased activity. An evaluation was made with the primary care physician (PCP), Phil Baty, MD, on the same day and the patient was diagnosed with probable adrenal insufficiency due to improper steroid taper and was placed back on a slower taper of prednisone. The patient showed rapid improvement in his symptoms. Unfortunately, after a week or so he regressed with more fatigue, sleepiness, polyuria and irregular INR results.

Overholt arranged for an office visit with the PCP, and it was determined the patient’s diabetes was out of control with a blood sugar over 400 mg/dl. The patient was started on insulin and Overholt trained the patient’s wife on insulin administration, glucometer use and treatment parameters. Teaching was also done regarding anticoagulation monitoring, and frequent medication reconciliation was done to keep up with dose changes that were required during this slower prednisone taper.

Over the next six weeks, Mr. F experienced irregular blood sugars, edema, urinary tract infection, and continued back pain issues. During this time, Overholt and Baty worked in concert to help the patient and his wife work through the various issues. The patient’s wife and Overholt talked on the phone one to four times a week and met in person each of the four times the patient was seen by the PCP in the office.

Today, three to four months after initial symptoms were reported, the patient is off insulin, off prednisone, has stable INR results, has his energy back, and is maintaining his weight. The patient was able to stay at home and receive all the support and care coordination needed through the CM/physician team. The patient did not ever have to go to the emergency room and was never admitted to the hospital during this time. He now is finally getting evaluated by the pain specialist for his back pain.

Dr. Phil Baty, the PCP states, “There is no way our team before the care manager joined could have provided the complex care needs Mr. F and his wife needed through these health crises. Stacey was instrumental in keeping the patient out of the hospital and out of the emergency room while allowing the patient to receive the information and guidance that he and his wife needed.”

 

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