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Here we present just a few examples to show how Priority Health works with
our members, doctors and hospitals to ensure that members receive the right
care. These stories are factual, but we have removed or changed certain
details to protect our members' privacy.
Help for a mysterious illness Keeping a member out of the hospital with an action plan Helping the mother of a toddler with asthma Arranging for a member with renal failure to use non-participating dialysis facility Finding relief for a member in continuous pain Diabetic member decided to be healthy Great weight loss without bariatric surgery Help for a mysterious illness One of our members had been hospitalized 18 times in a year and a half with a debilitating condition that made working impossible. We investigated the case and found poor coordination between the doctors and other health care services who were helping our member, and also found the member despondent about ever finding help. With permission, we sent the patient's records out of state for review by a specialist with experience in the condition, and worked with the member's primary care doctor to coordinate the recommended services. After beginning the new treatment regimen, the member is feeling well enough to lead an "almost normal" life, and has only been hospitalized once in 6 months. "You've given me my life back," the member said on a personal visit to our offices. Getting diabetes and depression under control A case manager called one of our members about her diabetes and high cholesterol and found her depressed. She wasn't taking care of herself; she wasn't checking her blood sugar at home because she felt "my doctor should do that," and it was sky-high. We helped her understand the damage that high blood glucose can do, and she agreed to go to some of our HealthyEncounters classes to learn more about how to deal with her disease. We also helped her get a new glucometer at no charge that she was comfortable with. She started getting more exercise and seeing a mental health counselor, and now her HbA1c is down to 7 and she's feeling much less depressed about her life and her diabetes. "I can't thank my case manager enough for all the encouragement," she says. Keeping a member out of the hospital with an action plan One older member with a long-standing history of asthma was occasionally hospitalized as his symptoms worsened over the years. His Priority Health case manager found that he was trying to treat himself based on his own understanding of what his triggers might be, and worked with his primary care doctor to refer the member to a specialist. The specialist did some allergy testing and then set up an asthma action plan for the member. Since then, the member has not needed to be hospitalized because he recognizes symptoms and can treat his asthma before it becomes severe. He is feeling much more confident about managing his disease. Helping the mother of a toddler with asthma After this very young member was hospitalized multiple times for respiratory symptoms, our outpatient case manager went for help to an agency which offers in-home asthma management education and services to parents of asthmatic children. The agency had previously begun to work with the member's mother but had stopped because she and the child had temporarily moved away. Our case manager persuaded the member's mother to work with the agency again, emphasizing that it was critical to her child's health. The mother is now seeing the agency's counselor regularly, and her child has not been rehospitalized. We follow up with quarterly calls to her, reinforcing the importance of participating in the program and praising her for the improvements in her child's health. Arranging for a member with renal failure to use a non-participating dialysis facility An older member was struggling with multiple complications of an illness, including renal (kidney) failure. He needed regular dialysis when he was discharged from the hospital, but the nearest dialysis unit in Priority Health's network was almost an hour's drive from his home. Our case manager requested approval for him to use a unit much closer to his home, and negotiated lower fees for some services as well as coordinating the rest of his post-hospital care. The member is now off dialysis, doing well and able to see participating nephrologists for follow-up care. Finding relief for a member in continuous pain A member was frustrated and angry that his previous surgeries had left him with severe, continuous pain. He was taking prescription painkillers morning and night, and his life was significantly limited. His case manager brought his case to our medical case review board, and worked with a Priority Health Field Service Representative at Priority Health to sign a new surgeon into our network with a successful track record in surgeries for the member's condition. The member saw this new doctor and had another surgery. "This member called me singing Priority Health's praises," reported the case manager. "His tone was bright and optimistic ...he reports his pain level is at zero!" Diabetic member decides to be healthy Our case manager called a woman who had been on insulin and oral medication for diabetes for many years who had recently attended a diabetic education class. The patient admitted that she was not following the prescribed diet and not exercising. Her body mass index (BMI) was almost double a "healthy" number. She and the case manager discussed the importance of diet, exercise and weight loss to improve her diabetes control. We also sent her educational information to review. Six weeks later, the member told us she was doing extremely well with her diabetes. From up-and-down, her blood sugar readings were consistently at 70-120. She was:
Great weight loss without bariatric surgery A very overweight member with high blood pressure and high cholesterol didn't want to undergo bariatric surgery. He and his case manager looked at many weight-loss options; he saw a dietician several times and tried all the diets suggested without results. Our case manager then suggested a hospital-based, physician-supervised program of liquid protein and exercise. In several weeks, this member lost more than 50 lbs. and lowered his LDL ("bad" cholesterol) close to 100 points. He tells us that he now walks much longer distances and is even able to exercise, and feels he has new control over his eating and his health.
Last modified
11/15/07
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