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Care Management and Support (CM)

Follow the transformative journeys of three patients overcoming various barriers to manage chronic conditions effectively under the CCM program. Witness improvements in health outcomes and quality of life.

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Care Management and Support (CM)

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  1. Care Management and Support (CM) Julie Woolstenhulme, Driggs and Victor Health Clinics

  2. CCM Patient A 33 years old female Dx -Diabetes II -Hyperlipidemia-hypertension Barriers: Financial, Heath Literacy, under insured, food insecurity, was living in a camper. Both parents died from complications of Diabetes in their 50s First seen in our clinic in 2014, had not taken any Diabetes medications in 2 years due to financial reasons. No HgA1c drawn due to financial reasons. Pt. was seen again in clinic one year later 2015 with c/o neuropathy symptom’s pt. has not been taking her Glucophage due to side effects. HgA1c 11.4Microalbumin+ Triglyceride 487

  3. CCM Patient A Continued… • Pt. was seen one year later 2016, pt. started on Lantus • Pt. was seen 3 months later blood glucose readings still between 236-448 • Pt. signed up for the CCM program 5/25/2016 • Weekly contact made with pt. to review medications, sometimes increasing dosages as needed. Blood glucose readings consistently under 200 now. pt. states “ I have not felt this good in 7 years” • Labs were repeated in 3 months her A1c was down to 7.5 • She is still in the CCM program even though she has moved and her A1C has only varied within a point but has never been above 9, her Triglyceride 183 she sees her endocrinologist and PCP on a regular bases now.

  4. CCM Patient B • 68 year old male • Truck Driver- Patient cannot use insulin while driving truck, Important to him to keep his CDL and gain control of his Diabetes on oral meds. • First seen on our clinic 2002 • Diabetes II-Hypertension • Barriers- Social Isolation-Health Literacy-Financial • HgA1c between 14.2 - 9.2 for the past 14 years • Pt. signed up for CCM program 5/12/2016 • Weekly contact with pt. helped to answer his questions and reinforce learning about his chronic conditions which translates into better control of pts. Diabetes • HgA1c went from 12.7 to 7.4 -6.9- 7.9 

  5. CCM Patient C • 55 year old Male • CHF, COPD, Anxiety • Ejection fraction 20% • Methamphetamine addiction for past 20+ years • Many Barriers- poor social situation, homeless, living in his car • History of non-compliance • Using the ED as primary care • CCM patient 6/1/2016 • Homeless shelter 12/1/2016 • Drug rehab/support • Pt now has a job/place to live • Has not used Meth • Takes his medications • Heart function has improved • COPD improved

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