Providing a Safe Place and Ongoing Care
At 47 years old, Mary had already faced more than her fair share of life’s challenges. Her medical history was extensive: heart disease, high blood pressure, high cholesterol, , a prior stroke, anxiety and low iron. Her physical health was compromised, with symptoms including slow speech, mobility deficits and high blood pressure. Despite needing physical and occupational therapy for muscle weakness, her progress stalled, and further therapy was denied.
Mary’s life took a turn for the worse when she was admitted to the ICU with necrotic pancreatitis and gastric ischemia. She endured multiple surgeries, drain placements and a wound vac placement during her extended stay. Her journey was further complicated by a history of sexual abuse, spousal abuse and inpatient psychiatric admissions.
How Conifer’s Personal Health Nurse (PHN) Helped
Amidst these overwhelming challenges, Conifer’s Personal Health Nurse (PHN) became Mary’s lifeline. The PHN’s dedication and meticulous care coordination transformed Mary’s trajectory from one of despair to one of hope and healing.
- Immediate Medical Coordination
The PHN reached out to Mary’s primary care physician (PCP) to arrange referrals for Neurology and Psychiatry appointments. This was crucial for addressing both her physical and mental health needs. - Community and Shelter Support
Recognizing the immediate need for a safe environment, the PHN worked diligently to find a shelter that would accept Mary upon her discharge from the hospital. This was no small task, given her complex medical needs and safety concerns. - Comprehensive Care Coordination
The PHN made a referral to the preferred behavioral health company and presented Mary’s case during Grand Rounds to ensure a holistic and collaborative approach to her care. Extensive education and coordination with community services were provided, ensuring Mary had access to the resources she needed. - Addressing Financial and Transportation Needs
Understanding the financial strain Mary was under, the PHN coordinated assistance for medication co-pays, transportation, housing and food. Her PHN also referred Mary to Social Security Disability Insurance (SSDI) for Mary, given she was potentially eligible. - Ongoing Monitoring and Support
The PHN engaged Mary’s facility case manager to assist with monitoring Mary’s progress and addressing any new needs. Continuous collaboration with Mary’s new PCP, behavioral health and inpatient providers ensured a seamless and comprehensive care plan.
Member Results
Mary’s situation began to improve significantly under the PHN’s care. She found safety and solace in a shelter, where she could heal from her recent acute health issues. She felt comfortable discussing her safety concerns with her PHN, who provided a non-judgmental and supportive space. Mary showed a significant improvement in her mental health stability. She received ongoing wound care and education on infection prevention. Her medical and behavioral health needs continued to be addressed collaboratively with the behavioral health provider.
Conclusion
Mary’s journey from despair to safety and ongoing care highlights the profound impact that dedicated, compassionate healthcare professionals can have on individuals facing immense challenges. Through the relentless efforts of her Personal Health Nurse, Mary found a safe place to heal and the ongoing support necessary to address her complex medical and mental health needs. Her story is a testament to the importance of comprehensive, coordinated care and the difference it can make in the lives of those in desperate need.
Individualized Approach
Personal. Health. Nurse.
Help members navigate the care continuum to find the right care, in the right setting, at the right time —go beyond episodic case management or chronic disease management.
Our Personal Health Nurses engage members and optimize benefit plan utilization through collaborative care management and heightened health literacy.
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Care Navigation
Dedicated one-on-one collaboration and care planning with a Registered Nurse
Disease Management
Goal-based programs care for the person, not just the chronic condition
Case Management
Support members most at-risk for high-dollar or ineffective benefit utilization
Utilization Management
Maximize member access to the right care, in the right setting, at the right time