Our team was alerted to Jane’s hospital admission. She was immediately assigned a dedicated Registered Nurse certified in case management. The case manager reached out to Jane, knowing by the sound of her voice that she was understandably scared. The case manager reassured her that she was there to help, but knew she had her work cut out for her.
Over the course of few months, Jane and her case manager developed a strong working relationship. She was diligent about going to scheduled appointments, listened to clinical advice given, monitored her blood pressure, and took medications as prescribed. Jane would call her case manager after every appointment to discuss the consult. When Jane and her providers struggled to manage her blood pressure, medications were changed and she carefully complied.
In early June, Jane called in distress. She was having considerable difficulty walking. She called her PCP and a CT scan was ordered. Nothing was found, but she continued to be symptomatic and her PCP was not responding to calls. At this point, the case manager brought in our on-staff medical director responsible for the medical advocacy program.
Collectively, the case manager and medical director intervened, persistently trying to reach the PCP. They finally connected with the PCP and an MRI was ordered. The MRI showed that Jane had experienced a fifth stroke. At this point, our team initiated a more aggressive approach to get her the care she needed, working to expedite her appointments with neurology and cardiology.
Additional testing was completed, Jane began physical therapy, and she was placed on the right combination of medications.