Chronic Disease Prevention & Management

The World Health Organization (WHO) reports that there continues to be an emerging global epidemic of diabetes that is directly related to the rapid increases in obesity and physical inactivity.

Lack of awareness about diabetes, combined with insufficient access to health services can lead to complications such as blindness and amputation. Although people may live for years with diabetes, their cause of death is often recorded as heart disease or kidney failure.

A Case Study of Diabetes Management

Robert is a 64-year-old widower who now lives in the independent living area of a continuing care retirement community in the northeast and has been living with Type II Diabetes since age 58. During this time, Robert has had to learn how to re-engineer his diet, get proper exercise and manage his insulin levels all while being the primary caregiver to his ailing wife. Additionally, Robert has 28 medications to take daily for other illnesses.

His 4 times per day blood sugar checks, improper insulin management and a non-compliant diet was the catalyst for an ongoing cycle of being sick, run-down and repeat hospital admissions for pneumonia for Robert. Left on this pace, he would become worse and his progression through the retirement center would be expedited to the long-term nursing unit.

Robert’s family utilized our Care Advocate services to assess Robert’s overall living environment and develop a care plan to identify and resolve obstacles that were preventing him from living to his potential. Our diabetes assessment included: a review of his medical history, communicating and coordinating with his physicians, family members and friends; and, direct observation of how he was navigating his daily life. We were able to identify the inefficiencies in his ability to manage his diabetes, which had a direct effect on his other health issues.

We implemented RN tele-health technology and protocol for a once-in-the-morning (instead of four) blood sugar check; installed a med alert system; hired an RN to manage his “pill-box” every two weeks and hired a home care aid to visit for one-hour each morning.

As a result, Robert starts the day out with the proper nutrition, manages his blood glucose and he no longer sleeps until noon and beyond. He makes his own lunch (on time) and has his evening meal in the community dining room. He has started to gain back the weight he had lost, enjoys a robust social life and gets plenty of sleep. He is now thriving.

Every year, according to the CDC, about 715,000 Americans have a heart attack.

Of these, 525,000 are a first heart attack and 190,000 occur in people who have already had a previous heart attack. Coronary heart disease alone costs the U.S. $108.9 billion each year. This total includes the cost of health care services, medications, and lost productivity.

A Case Study in Heart Disease Management

Tammy is a 63-year-old retiree with significant heart disease and has been told that somewhere in the future she will need a transplant and, at the very least, a Left Ventricular Assist Device (LVAD). Too young for Medicare and somewhat underinsured for this type of treatment, Tammy was overwhelmed with worry. Because she has very little family, her support system was fragmented at best.

A Patient Advocate from Putnam Health Advocates met Tammy through a referral and immediately began to put her mind at ease regarding how she would get through her healthcare journey including, how to pay her share after insurance; who would help her at home and what support system she would have. We were successful in helping Tammy implement changes that allowed her to be proactive regarding the decisions she and her doctors needed to make.

With a clear direction in place, Tammy educated and readied herself for what lay ahead. With help from our Patient Advocates, she was able to access community resources, apply and become eligible for needed benefits and utilize hospital education and heart disease support groups, which helped her make new friends. We took the intangibles off of her plate and let her breathe so she could focus on getting better.

Stroke is the fourth leading cause of death in the U.S., and while most stroke victims will survive, many will be left with devastating and life-changing disabilities.

A Case Study in Stroke Assistance

Damon is a 51-year-old successful computer project manager for a large distribution company. Unfortunately, a history of non-compliant and untreated high blood pressure led to a Hemorrhagic Stroke. The life he and his wife of 16 years enjoyed changed forever.

While still in inpatient rehabilitation, our Care Advocates were hired by his spouse to manage Damon’s discharge and assess and coordinate services he would need. His stroke had left him with right side paralysis and almost 80% blindness. Sadly, his career as a project manager was over.

Prior to Damon’s discharge, we immediately began coordinating and applying for his Long-Term Disability benefit through his work, while also applying for Social Security Disability Insurance (SSDI); both were approved quickly.

We developed a life-care plan so the family could understand and plan for the cost of care:

• Coordinated, interviewed and hired a home care service
• Managed all medical bills and insurance issues
• Researched and obtained best pricing for needed healthcare supplies
• Coordinated with out-patient rehab therapists and the insurance provider for ongoing services
• Researched and obtained prosthesis and negotiated pricing
• Obtained needed in-home mental health services
• Researched technology to improve mobility

Although his journey will be life-long, Damon has a direction to go in and will be ready as new technologies and therapies for stroke patients evolve.