Case manager helps seniors manage their conditions
Face-to-face meetings help build rapport
Georgene Siemsen, MS, RN, GNP-BC, visited the home of a 74-year-old patient at Bend (OR) Memorial Clinic because of concerns that she was not refilling her medication consistently. Inside, Siemsen found a disorganized collection of old bottles, expired prescriptions, and multiple refills of the same medications.
Siemsen — a nurse case manager for PacificSource Health Plan — is embedded in the clinic and works with at-risk Medicare Advantage members. She collaborated with the patient's pharmacist to develop an individualized medication chart that includes pictures of the actual pills she was taking and provided education and reinforcement on monitoring blood sugar and blood pressure checks.
Over time, with the assistance of the patient's primary care physician, her neurologist, and a friend who was helping with shopping, bill paying, and other tasks, Siemsen persuaded the patient to hire a caregiver to come to the home twice daily to supervise medications, assist with meals, and encourage socialization. "Her friend reports that the patient takes her medication consistently, has improved nutrition, and has consistently controlled blood pressure and blood sugar levels. By being intensely involved with patients in this manner, I can take whatever steps are necessary to help them adhere to their treatment plan," Siemsen says.
Siemsen joined the practice when the health plan began collaborating on a patient-centered medical home pilot project in 2010. She manages the care for 85 members who have multiple hospital visits, emergency department visits, and urgent care visits, as well as those who are at risk for interventions. She spends the time needed with her patients and gets to know them. "I work with the patients to establish trust so I can assist them in making decisions. Then we work together to develop a plan of care and do whatever is needed to help them follow it," she says. Since her patients know her well, they often call Siemsen directly when they have questions or concerns.
She may meet with patients after their primary care visits or ask them to come in for a special appointment. The meetings are held in a special clinic room that doesn't look like a medical office and has been furnished with comfortable chairs and artwork to make patients and family members feel welcome.
Some patients need only an occasional follow-up phone call, but others need more intensive follow up. Siemsen visits patients in their homes if there is a question about their support system or if she notices cognitive changes that may impact patients' abilities to care for themselves. She makes an assessment of the home situation and determines what gaps can be filled with referrals to community resources. "It is also extremely helpful when I can see firsthand the kind of system patients use to manage their medication," she says.
She often finds a collection of old medications in the medicine cabinet and, when appropriate, negotiates with patients to properly dispose of old medications. "Sometimes two medications look alike and the patients get confused," she says. She also assesses the home for fall risks and helps the patient eliminate them. For instance, she observed one elderly patient with a history of falls climbing over a pet gate to get to her medications.
In some cases, she accompanies patients to visits with their specialist to ensure continuity in care. For example, one patient with end-stage chronic obstructive pulmonary disease has a learning disability and a complex medication regimen. Siemsen goes with him to see his pulmonologist to help ensure continuity in care and helps him set up his medication box. Now, instead of waiting until his condition exacerbates so he has to go to the emergency department, he calls the pulmonologist when his respiratory symptoms worsen.
She often works with other members of the treatment team to come up with ways to help patients adhere to their treatment plan. For instance, she frequently collaborates with the pharmacist to create individualized medication charts that show what medications the patients need to take at what time. For one patient, Siemsen asked the patient how he would describe each pill and wrote the description on the chart.
Patients are identified through an open referral system and may be of advanced age, frail, have multiple chronic conditions or behavioral health issues, or have problems identified by the staff, she adds. There's no such thing as an inappropriate referral," Siemsen says.
Georgene Siemsen, MS, RN, GNP-BC, visited the home of a 74-year-old patient at Bend (OR) Memorial Clinic because of concerns that she was not refilling her medication consistently. Inside, Siemsen found a disorganized collection of old bottles, expired prescriptions, and multiple refills of the same medications.Subscribe Now for Access
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