Cookeville Practices Strengthen Community, Inspire Region
The VHAN network team and others in the Mid-South Practice Transformation Network have supported several practices in Cookeville, TN, in adapting to value-based care and improving services for their patients. These practices came together to share some of their accomplishments and best practices over the past few years. Their work is the result of the tireless efforts and dedication of the Transforming Clinical Practice Initiative (TCPi) team.
Nurse Care Coordinators, Pharmacists, and Social Workers support patients, families, and communities through coordinated, personalized care
“You brought me out of a fog and gave me a life again”
A retired nurse was struggling to manage her diabetes but was ashamed that she didn’t know where to start. She was also struggling with daily activities and was wheelchair-bound; she had been to the Emergency Room 13 times in five months because of severe leg pain. She had been to several different hospitals, and had been prescribed a large number of medications by different providers. A care coordinator and pharmacist met with the woman and her primary care provider several times to help reduce and explain the number of medicines she was taking. She was set up with mail order pharmacy so that she wouldn’t have to make several trips to pharmacies to keep up with her medication refills. She also received help in planning for what to do when she needed urgent care and how to manage her blood sugar levels.
Since she met with her care coordinator and care team, her blood sugar is under better control, and she has not needed to go to the hospital. Her pain levels have improved, and she has been able to get out of the house and move around. “You have no idea how thankful I am for all that you and your team have done for me,” the woman told her care coordinator. “You brought me out of a fog and gave me a life again and I am so thankful for you all.”
Making progress toward long-term health goals
A woman in her 40s was having a hard time getting control over her weight, blood pressure, and diabetes. She wasn’t tracking her blood sugar levels and wasn’t taking her medications because she felt like her doctor’s office didn’t communicate with her very well.
A care coordinator contacted the woman and helped her set up medication and meal plans that worked for her. The care coordinator also helped reconnect the woman with her primary care provider, and was able to motivate her to go to her scheduled appointments. Since then, she has gotten her recommended preventive screenings, and her blood sugar is under better control.
“I have made so many changes recently,” the woman told her care coordinator. “You are now my support and motivator to continue to do this. I keep the information you sent me in my car when I am in between [activities for her kids], and I pull this out as a reminder of my starting point and my end goal.”
Looking beyond the surface
A man in his 50s was struggling with hypertension and obesity. His foot had recently been amputated, and a care coordinator got in touch to offer help and support. The care coordinator spoke with the man’s wife, who said the one thing her husband needed was counseling to deal with the depression from his amputation. The care coordinator then connected the husband with a social worker, who provided mental health resources that could help him make an appointment with a counselor or therapist.
Making medications work for you
A man in his 50s was dealing with a range of conditions including anxiety, diabetes, ulcerative colitis, opioid addiction, chronic kidney disease, chronic pain, and a past stroke. He was taking more than 20 medications and was concerned about the cost. He was also having trouble remembering when to take which medications and admitted that he couldn’t keep up with them all.
A care coordinator connected the man with a clinical pharmacist, who helped reduce the number of medications the man was taking. In fact, one of the medications was causing the man’s ears to ring, a problem that was resolved after the pharmacist helped simplify the man’s medication list. The pharmacist also helped the man switch some of his prescriptions to a retail pharmacy that offered low-cost copays.
The man reports that his diabetes is under much better control and that his medication plan is easier to understand and follow.
Help with everyday needs
A woman in her 70s was dealing with several health conditions while living alone. She went to the gym regularly and stayed active, but her diabetes was not well-controlled and she needed surgery to correct poor blood flow in her legs, which was causing pain.
A care coordinator reached out to her to arrange extra help at home with everyday tasks such as meal delivery. The care coordinator also helped the woman understand how to take her medications correctly, which helped get her diabetes under control. Finally, the care coordinator helped schedule surgery to address her circulation problems and connected her with resources to make sure she could recover comfortably after surgery. The woman reports that she feels well supported by her care coordination team.
Support for child care and behavioral therapy for a special-needs child
A woman in her 30s was struggling to lose weight and manage a wide range of medical conditions including asthma, diabetes and ADD. She also had trouble caring for her autistic son, who needed special therapy. A care coordinator reached out to the woman and helped her apply for grants to pay for her medicines as well as behavioral therapy for her son. The woman was connected with support groups for parents with autistic children. The care coordinator also helped the woman work out meal plans, which helped her lose nearly 50 pounds.