logo
A A
facebookfacebookfacebook

Patient Stories

 

Patient 1

Status/Issues:

– 64 ER visits in 12 months
– No primary care provider
– Refusing mental health services
– Medically unexplained symptoms

Interventions:

– In home assessment completed
– Facilitated new primary care provider who diagnosed and initiated treatment

Outcomes:

– One ER visit over 7 months
– Self-managing symptoms with primary care provider and care coordinator
– Enhanced patient quality of life

Patient 2

Status/Issues:

– Multiple co-morbidities
– 20 ER visits in 12 months
– Felt criticized by primary care provider for over-utilization of ER

Interventions:

– In home assessment completed
– Determined patient access issues
– Primary care provider committed to provide timely access to office

Outcomes:

– No ER visits for 90 days
– Primary care accessed appropriately by patient
– Improved primary care provider and patient relationships

Patient 3

Status/Issues:

– Frequent falls and declining mobility
– Confusion
– Live in caregiver suffering burnout

Interventions:

– In home assessment completed and goals determined
– Referral to Senior’s Health for geriatric assessment
– Referral to Caregiver Recharge program

Outcomes:

– Follow up communication at 30 days identified new infection contributing to confusion and falls
– Patient remains at home with no falls in last 3 months
– Improved primary care provider and patient relationships