According to the CDC, over 600,000 people die of heart disease in the United States every year. The most common type of heart disease is coronary artery disease, which kills over 350,000 people a year. As an RN Care Manager, two key goals are to keep the patient at home and to prevent hospitalization.
Overview of patient
69 yo male with newly dx of Coronary Artery Disease (CAD), Hypertension, CKD Stage 2, Depression, Arthritis.
Signallamp Health’s Approach
Due to the patient’s multiple chronic conditions, the physician believed monthly monitoring would be beneficial to the patient and enrolled patient into the Chronic Care Management Program.
Mary Clare a registered nurse at Signallamp Health, reached out to the patient Robert for his initial call into the program. Mary Clare opened the call with “Hi Robert this is Mary Clare your RN Care Manager from Dr. Ozovek’s office. I am calling to get you started in the Chronic Care Management Program.” Robert replied with “Oh great, I was waiting for you call, I have so many questions about this new disease I have.. it is called Coronary Artery Disease.”
Mary Clare knows that there are several instructions that the patient will need to understand for him to manage his new diagnosis at home. But first she needs to assess his understanding of the diagnosis.
“Robert, tell me what you know about coronary artery disease?” Mary Clare said. Robert replied. “Well I know it has something to do with my arteries and my heart.” Mary Clare went into a patient friendly explanation of CAD and how it affects his body. Mary Clare also learned that patient is aware that this disease might lead to a heart attack if not properly managed, however patient reports that, “I am not sure of the signs and symptoms of a heart attack.” Mary Clare educates patient on the signs and symptoms of a heart attack and has patient write down instructions. Based on this brief but personal interactions, it is clear to Mary Clare that the patient needs further education on this disease process and she makes a plan of care with the patient.
Mary Clare reports her complex conversation, plan of care to physician, and asks if there is any other direction the physician might have for her.
Physician replies to Mary Clare to do bimonthly calls with patient until he understands his new diagnosis.
Mary Clare and Robert had multiple conversations about CAD, patient is in full understanding of his disease and is doing what is needed to manage this disease and to achieve a healthy lifestyle.
About Signallamp Health
Signallamp Health delivers a personalized approach to chronic care management. RNs are dedicated to your practice and collaborate with your care team to create one-on-one connections with patients outside of the office. Signallamp Health works seamlessly within your EMR (no integration required), provides care management services by RNs, and does so at no cost to the practice. Signallamp Health is good for your patients and good for your practice.
To learn more about Signallamp Health’s nurse-led care management services, connect with John Taylor at (610) 675-6887 or JohnT@signallamphealth.com. Find us online at www.signallamphealth.com.