Going Further to Educate and Provide Personalized Care

A 66-year-old client was in and out of the hospital due to Chronic Obstructive Pulmonary Disease (COPD) exacerbations. Though she had a Primary Care Physician, she would often visit the Emergency Department because she believed that she could not go to the doctor every time she needed something and that she could continue smoking without consequence.

This client has been widowed for 10 years but has great family support including a sister-in-law, a son who moved in, and helpful neighbors. The client doesn’t drive, has an education level of 10th grade, and is a heavy smoker. She has a history of COPD, Congestive Heart Failure (CHF), Hypertension (HTN), fibroids and heavy bleeding with an impending total hysterectomy.

Upon enrollment in our program, I set her up with initial goals including staying out of the hospital, medication assistance and transportation assistance.

Through my work, our client was approved for Maryland Transportation Administration Mobility Service which allows two trips daily with the cost of $2/per trip. She was more recently connected to the taxi card program in which she can pay $12/month and ride any cab service unlimited.

She is now taking four medications regularly and has consistently stayed out of the hospital for the past 90 days. She was provided a pharmacy drug discount card and instructed on its use, and she now uses RX outreach to order 90-day supply of medications.

Due to my client having reliable transportation while in the program, she is able to attend almost all appointments and makes the effort to reschedule those she cannot attend. Toward the end of her case management, she was calling to inform me of appointments and the results.

In addition to meeting basic medical needs, I provided my client with personalized education on the importance of paying attention to signs/triggers of declining health and alternative ways to improve it, such as increasing inhaler use, attending appointments in the earlier part of the day during hotter months and keeping hard candy around when feeling an urge to smoke.

She has become a conscious thinker of her health, having reported that she went from smoking 3-4 cigarettes a day to 1 cigarette every 3-4 days. She calls her doctor during after-hours and thinks first before visiting the ER. Because she is healthier at this time, I am helping her with a new goal of becoming more social.

Genevieve Clinton, RN Care Manager, West Baltimore Collaborative

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