A Plan for Success


Patient Characteristics
A 37 year old woman with a history of asthma, sleep apnea and an unhealthy weight was referred to our team after she was hospitalized for pneumonia. Upon discharge, we reached out to her and she was receptive to our call. She expressed concern related to her recent medical event and was overwhelmed with the new medications she was taking. She was also struggling to balance all of the commitments of her demanding job and family.

Care Coordination
We worked with her to perform a complete assessment that provided insight into her abilities to manage her acute condition as well as her overall health. We reviewed her home environment for how it may be impacting her respiratory symptoms and had her share with us what was important to her, how she defined health and wellness, and what some of her health goals were.

Together we developed a plan to reach her goals that worked within her schedule. Each subsequent call was targeted with a discussion related to opportunities to reach her goals. She attended her follow-up appointments, saw a specialist, and began to adhere to the treatment plan for her medications. She focused on taking care of herself and recognized the importance of this. She joined a fitness gym and we helped her save money on the membership through her health insurer’s website. She transitioned out of our program with a better understanding of how the health care system works, more confidence in maintaining her health, and knowledge to maximize her insurance benefits.