A nurse’s timely follow-up convinced her patient to get life-saving treatment.
While working as an embedded care manager within a primary care clinic, Ellen Woody, RN, met Mr. Gordon Harder, a patient with Type 2 Diabetes who struggled to control his blood sugar. Despite the doctor’s recommendation to take insulin, Mr. Harder refused. Ellen urged him to follow the doctor’s recommendation, but he was adamant that he could manage his blood sugar without insulin. Understanding that some patients need more time than others to make decisions concerning their care, Ellen gave Mr. Harder her contact information and encouraged him to call her if he had any questions or concerns.
Meeting patients where they are
During Mr. Harder’s next scheduled appointment, his blood sugar levels were worse. Ellen and the doctor visited with him, and they convinced him that he must take steps to better manage his diabetes or else risk serious complications. Although he continued to refuse insulin, he understood the severity of the situation and was willing to make some changes.
Over the next several months, Ellen and the doctor, along with Mr. Harder and his wife, worked as a team to manage Mr. Harder’s diabetes. Through this team approach — along with patience and education — Mr. Harder eventually agreed to try insulin, and the clinic helped him secure financial assistance to pay for it.
As Mr. Harder’s health improved, he grew more confident in his relationship with Ellen and with the doctor’s guidance. They taught Mr. Harder how he could better manage his diabetes while still eating the foods he enjoyed, and he trusted that Ellen and the doctor were making recommendations that were in his best interest.
Mr. Harder became very involved with his own care, and he was proud of his progress. After six months of incorporating better diet and exercise into his routine, his blood sugar levels improved significantly.
Although Ellen eventually moved into a new role, her relationship with Mr. Harder continued. Because they talk from time to time, Mr. Harder’s wife was able to share other medical concerns that her husband was facing. Of course, Ellen stepped in and coordinated with Mr. Harder’s care team to help.
“Being a patient advocate is a very important part of being a care manager,” said Ellen. “It can be challenging, and it takes time to earn a patient’s trust – but it’s incredibly rewarding when we break barriers and help patients enjoy healthier, happier lives.”
The Northeast Georgia Health Partners Network — which is a wholly-owned subsidiary of the Northeast Georgia Health System (NGHS) — is a network of over 1,600 community and regional physicians and hospitals, including those within NGHS and others across the region. Our providers work together to improve the quality of health care throughout northeast Georgia by providing clinically integrated care that is safer, more accessible, more affordable, and more effective.
Health Partners is committed to being the complete network solution for the customers we serve. To respond to the increasing emphasis on a value-based health care delivery system that is focused on quality and outcomes, Health Partners developed a clinically integrated network (CIN) called HP2. HP2 is a network of like-minded providers that share data and information and follow consistent clinical programs and protocols. HP2 develops, negotiates, enters, and administers contracts with employers, payers and other parties to deliver health care services to their employees or other covered individuals, and the services are delivered by providers in the CIN.
Health Partners also formed the Northeast Georgia Health Partners ACO, which fosters collaborative relationships throughout the entire continuum of care and brings greater benefit and value to the Medicare beneficiaries we serve. All participating providers in our ACO—primary care, hospitals, specialists, and others—share the responsibility of coordinating patient care, with goals to improve care, reduce redundancy and lower costs.