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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.
Keeping a member out of the hospital with an action plan Educating a diabetic member about the dangers 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 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. Educating a diabetic member about the dangers of giving her body "a break" from medication A member had been successfully managing her diabetes for five years, at first with diet, then with the help of oral medications. Then she decided to stop taking her medications because she felt her body "needed a break" from them. Her blood sugar level started to skyrocket, and her doctor prescribed a new medicine. However, she began to have side effects and wanted to quit taking it. Her Priority Health nurse case manager worked with her to help her understand how diabetes progresses and how important it is to take her medicines and follow her doctor's instructions. The nurse also helped the doctor understand how uncomfortable the member was with the side effects. Now the member is on a new medication, and her diabetes is well-managed. 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
10/02/08
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