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:
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:
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:
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