CCM from CCS: Patient Success Stories

Story by CCS Editor / May 23, 2023

Chronic Care Management services from CCS provide patients with a direct phone line to a qualified, empathetic Care Coordinator who serves as an extra set of ears and eyes for the patient while closing gaps in care. Chronic Care Staffing invites you to read a selection of real patient success stories from the past year, to show the many ways CCM benefits both our patients and clients.

Focus on Social Determinants of Health (SDOH) via CCM Improving Clinical Outcomes

● We have one patient who regularly expresses her appreciation for the education and encouragement with diet and exercise she receives during her CCM calls. She has stated that she feels “judged” by friends and family members because they do not understand her medical conditions or the type of pain she has at times. She said that the people around her regularly criticize her when she can’t do certain activities, which makes her feel as though she shouldn’t bother. The patient said that her monthly calls are the only thing that motivates her to “keep trying” with exercise and making healthy choices. On follow-up calls, this patient is usually happy to talk about progress, highs and lows with activity levels, and tell the Care Coordinator when she has been walking more or doing more to try and reach her activity goals.

● I spoke with a patient last week who was blind and lived alone with only his ex-wife as an emergency contact and he had no heat during the cold snap we recently experienced. He told her he was cold and could not afford to get fuel oil at this time. She reached out to the care advocate, but they said that, since the cold weather had hit early this year, most of the agencies with resources were too overwhelmed to offer help. I got the contact information for the patient’s heating oil provider and spoke with a very kind and helpful lady. She has a direct contact with the SHARE program, and someone who gives people a full tank once a year. Thankfully, we were able to work together and get this patient taken care of. He now has a full tank of fuel oil and will be warm for the next several months.

● I spoke with an elderly patient who mentioned she had trouble buying food. She did not see the SNAP renewal application form in the mail, so they canceled her monthly SNAP benefits. After speaking with her I contacted Planning and Development to see if she could get any type of assistance, and they took her information from me. When I called her the next month and asked if she had heard anything from them, she responded, “Someone knocked on my door one day, and when I answered the man had a bunch of groceries. He said they were for me and all I could do was holler; I was so happy!” She expressed her appreciation to me and told me how much the weekly food deliveries have helped her.

● I have a patient who typically sounds cheerful when I call. But during this month’s call, she didn’t sound like herself. When I asked her how she was doing, she said that she had gotten into an argument with her adult granddaughter who lived in her house. She told me that the granddaughter had punched her in the eye, and she was having some eye trouble. I asked her if the police had been called and she said yes. The police came and CPS came and made a report, but the granddaughter was not removed from the home. I asked her if she felt unsafe and she said no but had hoped the granddaughter would be removed from the home. I advised the patient to be seen by a Provider for evaluation and she agreed. I sent an urgent telephone encounter to the Provider and Social Work team and they got the patient in for evaluation the next day. The patient was sent to Ophthalmology for an eye exam. When I followed up with her, she was grateful that our team had reached out to her. She reported that her granddaughter was no longer living at her home and her eye has improved.

● We had a Spanish-speaking patient who was scheduled for a procedure. He was getting pre-op calls in English and was not sure what he needed to do or where to go. He gave me a call and after a bit, I was able to get him scheduled for his pre-op Covid test and provided him the address and time for the procedure and his pre-op instructions. He was very thankful.

Care Coordinators Manage Changes in Patient Conditions to Save Lives

● One of my patients called in to let me know her blood pressure had dropped, and she wasn’t feeling well. She stated she was scared and all alone. She also said she felt like she could pass out. While keeping her on the phone I called 911. I kept her on the line, insisting she stay calm and keep talking to me. I informed her the ambulance was on the way. While we spoke, she had a visit by her landlord’s son who stayed with her until the ambulance arrived. I spoke with the patient the next day, who said she was feeling better and appreciated having a number to call when she was scared and not thinking straight.

● The patient is a young man, overweight, and on dialysis. We discussed exercise, which he agreed to, and we gradually increased activity as tolerated. I encouraged him to discuss his diet options with the dialysis clinic. By acting on these two recommendations, he started losing weight. Now, he has lost enough to be able to qualify for a kidney transplant. He is currently working with a transplant coordinator to get a new kidney and will hopefully have a long, fulfilling life ahead of him.

● A regular monthly call quickly escalated when the patient expressed a desire to harm himself. Not only did he have a plan, but he also had the means to carry out his plan. Through the quick thinking of the Care Coordinator, the Team Leader was able to notify EMS and police, and the patient was safely transported for emergency psychiatric care. His follow-up behavioral health care was scheduled before he was even discharged. Because of this Care Coordinator, the patient is doing much better and is getting the care he needs.

● A patient mentioned he was having trouble with eating and with swallowing his medications. At the time he thought it may be due to not having any teeth. He went to a dental office, and they sent him to another location for x-rays. When he arrived, he found that the cost was too much for him to afford. He told me he had given up on trying to get dentures. After we spoke, I called around and found a dental office nearby. They said that, with his insurance, they could provide him with a complete set of dentures with no out-of-pocket expense. I scheduled him for an appointment, and he received the dentures at no cost.

● I called to enroll a patient for CCM services, which she accepted. After speaking with the patient, she began to tell me about a new symptom she had been experiencing for a couple of days. She described a tingling/numbness radiating down her left arm and left side of her face. I advised the patient to have her family member take her to the ER for an immediate evaluation, as a precaution. The patient called me that evening and reported that she had suffered a stroke and had been admitted to the hospital. She thanked me for “saving her life!” This patient is now doing well and continues to enjoy CCM monthly phone calls.

● We enrolled a patient last month who was complaining of ongoing pain. When the Care Coordinator asked if he took any medications, he said the words “over the table” – an unusual response that she asked him to explain. Through further questioning, she found that he had been self-medicating with street drugs, saying that he would take “whatever he could get.” The Care Coordinator sent an alert to the PCP who might not have otherwise known the patient was doing this.

CCM from Chronic Care Staffing Drives Patient Success!

CCS wishes to recognize and celebrate our Care Coordinators who help deliver positive outcomes every day – the patient success stories that make the headlines and the ones that don’t. And these same dedicated care professionals are ready to go to work for your practice or health system. We invite you to learn more about our CCM services at our website, and then give us a call!

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