Cambridge Health Alliance’s complex care management (CCM) program involves teams of care managers helping patients make their medical appointments, adhere to medication regimens, and handle the various obstacles they face to improving their health.
The following are two case study examples of how the program works:
• The very ill single mother: The mother of two young children had mental health and substance use issues, and was seriously ill. She enrolled after visiting the ED for treatment of diabetic ketoacidosis, says Alex Harmon, LICSW, a complex care manager with Cambridge Health Alliance.
“Before that visit, she had missed multiple primary care visits, mismanaged her diabetes, and was dealing with complex substance use challenges,” Harmon explains. “The Department of Children and Families also had begun to get involved with her family situation.”
The patient had been skipping meetings with her PCP, so Harmon and the PCP met with her to develop a management plan.
“We created a safe environment where she felt like she could be honest about her mental illness and learn that all of her issues were interconnected,” Harmon says. “Once that relationship was formed and her challenges were validated, the patient began seeing specialists, scheduling and attending primary care appointments, and also got placed into an addiction treatment program.”
In the five months after that first meeting, the patient visited the ED only one time and has become much healthier, Harmon adds.
“Because we took the time to form a lasting relationship with her and to meet her on her own terms, she trusts us and feels like we have her best interests at heart,” Harmon says.
• The elderly woman with family stress: An elderly woman with uncontrolled diabetes, chronic depression, and family stressors was referred to the CCM program last summer.
“She was carrying the weight for her family, putting their needs first and her own health suffered,” says Mérida Brimhall, RN, a complex care manager with Cambridge Health Alliance.
The patient’s sons abused alcohol and were facing jail time. The patient ended up in the ED about once a month, and she also had two inpatient stays at an outside hospital. Her health issues resulted in surgery and imaging services, Brimhall recalls.
“She was not caring for her diabetes, her mobility was limited, and she was isolated in her home,” she explains.
With the CCM team’s help, the patient developed a care plan. After building rapport with the patient, the CCM team worked with her primary care provider and clinic-based staff to tackle her healthcare needs.
“We listened to what her goals were, validated her struggles, and developed an actionable plan with steps toward her goals,” Brimhall says.
They also helped her get a patient care assistant, food stamps, and connected her with a day program. “I worked on educating her about her medications, disease process, and fall prevention,” she adds.
In the six months since she was enrolled in the CCM program, the patient returned to the ED only twice and has not had any inpatient stays, Brimhall notes.
“Most importantly, she feels empowered to take care of her own health and has made great strides toward a healthier life,” Brimhall says.