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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) Julie Woolstenhulme, Driggs and Victor Health Clinics
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
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.
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
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