Care management nurses have the opportunity to provide support and coordination of care to our patients. The following is one of our stories:
Patient is a 55 year old with hypertension, diabetes, Afib, COPD and obesity. When the Care Management nurse started working with this patient, blood sugars were out of control with Glyco-Hemoglobin (HbA1c) of 12.1. Patient checked blood sugars twice a day with results in the 300 to 400 range. Over the next few months, the patient was overwhelmed with having eye surgery, UTIs, and a foot ulcer. Barriers to decreasing blood sugar were infections which necessitated the use of antibiotics and steroids. Patient had limited mobility due to the foot ulcer. Despite these barriers, the patient was able to decrease blood sugars into the 200s with HbA1c going from 12.1 to 8.8.
With continued support from the entire health care team, including the primary care provider, community health coordinator, care manager nurse and nutritionist, the patient was able to decrease blood sugars into the 150s with HbA1c dropping from 12.1 to 7.0 over seven months. The Interdisciplinary Care Team is the optimal and most effective method to delivery high quality health care and support to our patients.