On the Path to Wellness: A Care Management Success Story

Debbie Platt describes the fall of 2016 as one of the most difficult times in her life, and although she didn’t know it at the time, it turned out to be the biggest turning point for her health.

Debbie – along with her husband, Kenny, and her son, Joshua – had recently moved out of Port Leyden, a small Lewis County village she and her family had called home for 22 years. Due to multiple medical issues and limited mobility, Debbie no longer felt safe in their home and decided to relocate to Carthage.

Shortly after her move, Debbie developed a severe leg infection and was rushed to the emergency department at Carthage Area Hospital. It was during that hospital stay that she met Dr. Hardik Patel, who would eventually become her Primary Care Provider.

Already upset with the way her life was going, this visit to the hospital brought Debbie to her breaking point. She remembers breaking down during one of her follow-up visits with Dr. Patel:

“I was at my wit’s end,” she said. “I just couldn’t seem to get better. Physically and emotionally, I was not in a good place. I needed some help but I didn’t even know where to start.”

Recognizing that Debbie could benefit from care management services, Dr. Patel introduced her to Tammy Potter, an RN care manager at Carthage Family Health Center. It was at that moment that Debbie’s path to wellness began.

Care management aims to improve patient care and reduce the need for medical services by enhancing coordination of care, eliminating duplication, and helping patients and caregivers more effectively manage their health and wellness. While this concept is relatively new to the primary care setting, it has proven to be extremely effective in managing patients like Debbie who have multiple chronic conditions.

Debbie’s care management program began by working with her husband and Tammy on a care plan. A care plan is a detailed approach to care, customized to an individual patient’s needs.

care management“We created Debbie’s care plan with a very patient-centered approach,” Tammy said. “We really focused on encouraging her to become an advocate for her own health care.”

During the initial care plan meeting, the trio set and prioritized goals for Debbie’s health. Her goals included: setting up reliable transportation; prioritizing and scheduling referrals; stabilizing her blood pressure; losing weight; increasing mobility, and improving mood.

Because of her medical issues, Debbie had always struggled to find transportation, which prohibited her from attending appointments in the past. However, since forming her care plan, she has received help from the Volunteer Transportation Center. She credits much of her success to her driver, Darin Keggins.

“I can’t even begin to tell you how amazing Volunteer Transportation is,” she said. “Darin always treated me like a person. He always puts me in the front seat right next to him. He’s never treated me like I’m ‘cargo’, he treats me like a person, like a friend.”

Tammy and Debbie both agree that open, honest communication and a willingness to change are crucial to a successful care management program.

care management
Debbie Platt gets a hug from Tammy Potter, her care manager.

“Tammy has a way about her,” Debbie said. “She is honest with me and tells me what I need to do but she also motivates me. She never judges me. I feel like no matter what happens, I can get through it with her by my side.”

Tammy and Debbie’s genuine relationship feels more like a friendship than a care manager/patient relationship. They talk on the phone at least once during the week and meet in person any time Debbie has an appointment at the clinic.

However, Debbie’s path to wellness has not been a flat road. She has met her share of challenges along the way.

In May 2017, she presented to the Emergency Room with pain, swelling, and drainage in her right index and middle fingers after slamming her hand in a car door three weeks prior. This accident ultimately resulted in a partial amputation of her fingers.

Thankfully, though, Debbie had her entire care team there to help get her through the traumatic experience. The Volunteer Transportation Center provided her with transportation to her appointments at Syracuse Orthopedic Specialists, and once she returned home, Samaritan Home Health provided in-home physical therapy, occupational therapy, and nursing – all the while, continuing to communicate with Tammy about her progress.

“I couldn’t have done it without them,” Debbie said.

Currently, Debbie is working with Susie Kim, a nutritionist at Carthage Area Hospital, to address nutritional deficits and continue to work on a plan for weight loss and management. She has lost nearly 100 pounds and decreased her BMI from 56.5 to 49.6. She uses the “My Fitness Pal” app on her iPhone to log all her meals and exercise activities, and Susie can login to see her progress and make suggestions.

Debbie had Bariatric Surgery 7 years ago, lost 110 pounds in 6 months, but unfortunately gained all the weight back, plus additional weight. This time, however, with the support of Tammy and Susie, she is confident about her weight loss, saying it feels good to do it “the right way.”

“Care management has changed my life; I have a whole new outlook,” Debbie said. “I can’t wait to see what’s in store for me. I know it’s only going to go up from here.”

Debbie has not had any hospitalizations or emergency room visits (other than for her hand in May) since being enrolled in care management. Within the past 5 years, Debbie states she had approximately 22 emergency room visits which resulted in 20-22 inpatient hospitalizations with 6 of those being crisis

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