Treating the Whole Person

Barbara,  a 60-year-old from Milwaukee, had a complex set of health issues, including chronic obstructive pulmonary disease (COPD), sleep apnea, and chronic pain due to degenerative disc disease. She was seeing a primary care provider and several specialists, but her breathing problems and chronic pain continued, leading to seven emergency room visits in just six months.

Barbara’s case manager tried to call her multiple times but was never able to get through. That’s how Barbara ended up on the caseload of Mary Kay Carron, a case manager who focuses on helping members in the top 5% of health care usage.

“I had to do some detective work to track her down, but that’s part of our role, to 
be out on the street,” said Carron. “When I found her, she was very receptive. She told me she was seeing several doctors in several different places, but things weren’t getting any better.”

Carron said Barbara’s pulmonologist was seeking to identify the real problem. “She told me he had said, ‘No one’s looking at you as a whole person,’” Carron said. “The left hand didn’t know what the right hand was doing.”

Indeed, Barbara was getting a lot of care, but it was unfocused and uncoordinated. “The PCP she had been seeing was independent, so he wasn’t affiliated with any of the major health systems in the Milwaukee area,” said Carron. “When it came time to refer her to a specialist, he wasn’t necessarily thinking about keeping all his referrals within the same health system.” In addition, when Barbara would visit different emergency rooms, the staff didn’t have access to her medical records so they didn’t know which providers she had been seeing. As a result, they would schedule follow-up appointments for her with yet another set of doctors.

“She was just going in so many different directions,” said Carron.

Overwhelmed, Barbara had begun to miss her scheduled appointments. “That’s something you really don’t want to happen,” said Carron. “In some practice areas, there aren’t that many specialists, and if you miss appointments, you risk getting a letter that says, ‘You’re no longer welcome at this clinic.’”

To turn things around, Carron  turned to the Froedtert Health System. “I knew she needed a single place that would provide primary care and all the different specialists she needed,” said Carron. “I wanted her to have a seamless experience.”

Froedtert had a waiting list, so it took some time to get Barbara started with a PCP there, but once she did, she had access to all the specialists on staff. Carron made Barbara’s transportation arrangements, gave her reminder calls and met her at her appointments. “She was a champ, working hard to keep all her appointments and follow up with her treatment plan,” said Carron. Other team members helped Barbara with her non-clinical needs, such as independent housing, personal care services and in-home medical equipment.

The journey wasn’t all smooth sailing. “She had moments when she felt angry or frustrated with everything she had to do,” Carron said. “I just listened and reframed the way she was thinking about things, making sure she understood her plan of treatment. That helped her feel better and calm down.”

Barbara is now well established at Froedtert, where her PCP and specialists are working together to provide the coordinated care she needs. “She’s seeing a pulmonologist for her lung issues and a sleep specialist for her sleep apnea, having her blood checked at the coagulation clinic and doing physical therapy at the pain management clinic,” she said. “She’s gotten off the opioids she was taking for pain, and she doesn’t have the anxiety that used to make her breathing problems worse.”

The result? Barbara has gone from seven emergency visits in six months to zero. With Barbara’s health on track, Carron has now transferred her back to a telephonic case manager, who checks on her monthly. Barbara is free to call Carron, however, whenever she has questions or just needs to talk.

Carron says she would welcome such calls. “Sometimes I think it’s harder on us to transfer our members than it is on them because we get so attached,” she said. “But I know she’s established with all the doctors she needs, her medications are stable, and her treatment plan is in place, so it’s the right time for me to back out.”

Carron says Barbara’s experience demonstrates the benefits of holistic, coordinated care. “It bothers me greatly when people are looked at as a set of health problems, instead of as whole beings,” she said. “It’s wonderful to see what happens when everyone works together, treating a patient as a whole person. Sometimes it takes a little longer, but it’s worth it.”