Creating an Excellent Patient Experience: In Sickness and In Health
Connected Senior Care Advantage, in coordination with Austin Regional Clinic, Premier Family Physicians, and Capital Medical Clinic strives to create proactive, healthy, patient-directed focus on wellness and helping our patients manage and maintain good health.
The process of meticulous chart review that happens in advance to the annual wellness visit has helped me to become more deeply reacquainted with some of my patients. - Rudxandra Aguiar, MD, Austin Regional Clinic
But as our patients’ bodies age, chronic conditions and acute health events can create challenges for their health -- so we work tirelessly to harness the data and clinical resources to create an exceptional patient experience. Below are a few stories about our post-acute care that demonstrate our aim of serving our patients with the utmost in seamless and coordinated care designed to maximize quality of life while delivering good outcomes.
Enjoy reading a few of these stories about our patient care. The names have been withheld to protect patient privacy but are representative of the type of care and attention our Connected Senior Care Advantage patients receive with their program.
Just today, I saw a patient that our pre-visit chart reviewer had marked as having protein-calorie malnutrition. As I reviewed the chart, I could see that she had been slowly losing weight over a period of time. During my discussion with her, I found out that her appetite has been slowly decreasing over the last few years and she just nibbles at things. I was able to give her Ensure samples and advised her to drink 1 or 2 daily. I met her daughter in the waiting room and she agreed that her mother needs more calories and proteins and made a plan to support her in this. -- Gurneet Kohli, MD, MBA, Chief Medical Officer Premier Family Physicians
Senior Woman w/ Hypertension, Chronic Kidney Disease and Diabetes
This senior female patient had a history of hypertension, chronic kidney disease and diabetes. She began to experience upper respiratory problems and started on antibiotics. During the course of treatment, she came to us with fluid accumulation in the tissue and air spaces of her lung, which can sometimes result in the inability to breathe and cardiac failure.
The care team at Connected Senior Care adjusted her diuretics to expel some of the liquid and had repeat x-rays to confirm improvement. As the patient started to heal, they scheduled frequent phone conversations (15 in a month) to get updates on progress and explain test results and continued the conversation to ensure progress in her healing.
This approach enabled the patient to recover in the comfort of her home without going to the hospital.
Pancreatic Cancer Amid Complex Conditions
A patient began to feel very weak at home and her urine turned dark. She went to hospital to have tests and discovered she had pancreatic cancer. She already had complete failure of her kidneys, further complicated by gastrointestinal bleeding.
The Connected Senior Care Advantage team quickly identified these multiple conditions and was able to coordinate care. They found a rare skilled nursing facility that provides dialysis onsite as well as 7-day-a-week MD coverage.
The patient’s primary care physician came to visit the patient and her husband within two days of her arrival to explain the new diagnoses and provide moral/social support.
As a result both the patient and the family felt cared about and much more at ease at the rehab facility.
Elderly Male with Dementia
This patient was experiencing moderate and worsening dementia in his later stages of life. He had been hospitalized twice in the prior 3 months for heart problems. The experiences were fairly traumatic for him and his family did not want him to be put through any more procedures, but he was told at the hospital he was not ready for hospice care.
The Connected Senior Care Advantage team communicated with a skilled nursing facility both the patient and family’s wishes before the patient even arrived and helped enroll him in palliative care. He was treated with comfort-oriented care per their expressed wishes.
New episode of symptoms occurred on second night which previously would have resulted in a frightening 911 call and emergency room visit, but the patient was made comfortable at the skilled nursing facility and passed away a few days later in a tranquil environment surrounded by his family.
Easier Access to Care for Assisted Living Patients
Often patients living in assisted living facilities need transportation to see their PCP in the clinic. Recently, four patient residents of assisted living facilities were able to have the benefit of an onsite nurse practitioner visiting them at the facility two to three times per week.
The end result was that they retained the primary care physician they had known for many years and received the benefit of an expanded care team to serve their needs. They received their care in the comfort and convenience of their home.
High Touch for Very Sick Patients
Two recent patients who were very sick and in the hospital (one at CPRMC and one at Seton Wilco) received care from a friendly Connected Senior Care Advantage palliative nurse practitioner, who visited multiple days while they were in their respective hospitals.
When discharged to their home, the same nurse practitioner came and did a home visit, representing a continuity of care that is rarely seen in the field of patient care and was highly valued by these patients.
As a result, the patients and their families gained great trust and confidence in the caregiver and benefitted from the strong relationship they formed.