Member Story: The Will and the Way

Background

When we first saw Ms. Q in February 2017, she was suffering from diabetes, acute hypertension symptoms, renal failure, COPD, peripheral neuropathy, and retinopathy.

She was also struggling with so many of the barriers to care faced by impoverished or underemployed Black people in the inner city. This manifested in Ms. Q’s lack of trust with the staff – and a lack of interest in helping herself.

Ms. Q needed care management in the form of nutrition counseling, social work, diabetes education, and treatment for a skin rash (as well as a solution for her acute hypertension symptoms). But she was not competent with following medical advice: she refused to learn how to take her medications and didn’t trust the reasons for needing them; she did not wish to follow the recommended diet; she expected the AbsoluteCare staff to cater to her every need; and she refused to begin a nephrology-recommended plan of two years of dialysis. Perhaps worst of all: her family refused to be involved in her care.

Method

Here’s how we worked with Ms. Q to improve her health through our chronic care model.

• By supporting her emotionally, we were able to get Ms. Q to consent to a 3x/week dialysis treatment in February 2020 and she is now living with dialysis and receiving the treatment she needs. 
• We coordinated home health services, oxygen support, and a wheelchair.
• She monitors her blood sugar with Dexcom and our pharmacy’s support, and better understands this condition thanks to diabetes education.
• She prefers in-house visits to phone calls.
• She better understands the reasons for her renal diet and fluid restrictions.
• She has developed a strong relationship with her nutritionist.
• We have provided behavioral health counseling and medication for depression.

Results

With care management (going Beyond Medicine) from the AbsoluteCare staff, Ms. Q’s life has changed dramatically.

• Her weight and blood sugar are both stable; her A1c was 6.6 in July 2020, down from 8.5 in October 2019.
• While living with dialysis, she has built trusted relations with our skilled nurse and 3x/weekly personal aide.
• She is medication-compliant and keeps appointments, and she always meets quality measures.
• She had two hospitalizations in 2020 due to complications of end-stage renal diseases; however, she had no ER visits for acute illness in the same year.
• Ms. Q uses a rollator when she is able.

Finally, Ms. Q has become grateful for her life and for her family, through help received using AbsoluteCare’s chronic care model. In just two years, she has developed both a way – and a will – to live.