Frontline Innovation: Frail Elders Care Management (Health Care Innovations Exchange)

Uploaded by ahrqinnovations on 04.03.2011

My name is Dr. Kyle Allen and I’m the medical director for
Post-Acute and Senior Services at Summa health system.
We worked on really wanting to focus on older adults who are of
low income but also had chronic disease and functional impairment.
Pat’s a kind of prototypic example, kind of our poster child, if you will.
Pat had underlying medical problems,
including diabetes and hypertension,
didn’t have a really good knowledge and understanding of
her health issues, and so she was having exacerbations of her
illness, requiring her to go to the doctor or go to the hospital.
She didn’t have any set goals and targets for what her
blood sugar should be, what her cholesterol should be.
She had a knowledge deficit.
She was very overwhelmed by the system, as she said.
So that overwhelmingness of trying to navigate all the
pieces and parts that she needed for her healthcare as well as
her social needs just led to inaction.
The patient was seen in their home after discharge from the
hospital and through this intervention we wanted to try to
see if we could activate the patient for self-care.
The care manager really focused on getting Pat to set goals.:
recording her blood sugar so she can take this to the physicians,
understanding what her hemoglobin A1C needed to be,
what she needed to do from a diet and exercise perspective…
I think once Pat started having more success with her diabetes,
you know, then she felt more empowered and more engaged.
I can do this, I’m just not a passive participant in this,
it’s not all up to my doctor, it’s really up to me.
I’m Dr. Kyle Allen, and I’m a healthcare innovator.