Patient Stories

Medicare patients of BJC Medical Group doctors, after contact with their doctors, can choose to participate in the nurse care manager service as a part of BJC Accountable Care Organization.

Nurse care managers call patients when they are discharged from the hospital, or when they have been identified as being at a high risk of hospital admission due to chronic disease. Nurse care managers will also follow up with patients for several months if needed.

Finding the Right Doctor Makes a Big Impact on CHF Patient

Don, 36, had been hospitalized six times in under a year for congestive heart failure (CHF). After his last hospitalization in January 2014, a nurse care manager contacted him and followed him for the next five months.

How Don's nurse care manager helped:

  • She taught him about his disease, a proper diet to follow, and how to take his medication correctly

  • When she discovered that he was not keeping his doctor appointments with his primary care physician because he did not feel comfortable with the doctor, she found a new one he was comfortable with

  • She helped him quickly see the doctor, and he has continued to take his medication and keep all of his follow up appointments

Don's patient testimony:

  • He loves how he now feels

  • He has not had any more issues or hospitalizations to date

Helping Adjust to a New Life After Amputation

When Dee was discharged from a rehabilitation facility after having her leg amputated, a nurse care manager reached out to her to help her adjust to the changes in her life.

How Dee's nurse care manager helped:

  • She was able to move Dee’s follow up appointment with her primary care physician to three weeks sooner than originally scheduled

  • She was able to arrange transportation so Dee could keep her appointment

  • Within the week of her discharge, the nurse set up BJC Home Care Services to provide visits and rehabilitation in her home

Dee's patient testimony:

  • Dee was very happy with the help she received transitioning into new routines

  • She was able to find a new place to live with improved accessibility

Answering Questions Can Mean Fewer ER Visits

Sandra had been a frequent user of emergency services for symptoms she believed were urinary infections. The nurse care manager contacted Sandra following one of these ER visits and developed a rapport. 

How Sandra's nurse care manager helped:

  • With comfort and trust, Sandra began calling her nurse with questions rather than just going to the ER

  • They found her symptoms were from a variety of causes, including medication side effects; Sandra is now seeing her primary care physician regularly and being treated for chronic back pain

Sandra's patient testimony:

  • She has also given up smoking; the medication side effects are better-controlled with a few changes

  • She has not been back to the emergency department for a year

From Ice Cream to Independence

Kathleen, 57, was a frequent user of Christian Hospital’s emergency room, always arriving by ambulance. She was a smoker with swallowing issues and breathing problems, and was unable to leave her home for very long.

How Kathleen's nurse care manager helped:

  • Working jointly with the Community Health Access Program (CHAP) at Christian Hospital that uses a paramedic to visit patients in their homes, the nurse care manager identified key issues for improvement

  • Issues such as trash build-up, which was due to Kathleen’s inability to walk to the dumpster, and other medical and psychiatric issues were addressed to improve her quality of life

Kathleen's patient testimony: 

  • Kathleen has gone from only eating ice cream to eating healthy meals and has decreased her smoking

  • She has a cleaner home with better air quality and is now able to walk to the drug store to pick up her prescriptions

  • Her calls to 911 have dropped from five times in a week to no calls over four weeks

  • She is keeping her doctor appointments and has not been to the ER for three months