Our team seeks to improve health outcomes, reduce costs and increase quality for our patients throughout the continuum of care.
Henry is a 69-year-old male with hypertension, GERD, hyperlipidemia, OSA, and uncontrolled type 2 diabetes mellitus with fasting glucose consistently in the 200-300 range.
Henry is unable to afford his insulin. He changes his dose of insulin to make it last longer when he doesn’t have access to samples. His blood sugars are consistently high.
Katherine, PharmD worked with Henry’s benefit plan to identified the preferred insulin. She collaborated with the PCP to transition him to the preferred insulin so Henry could afford it.
During the episode, it was identified that Henry also could not afford a gym membership to maintain consistent exercise.
Henry was referred to a SoNE CHW who helped him to find a discounted gym membership rate through his benefits.
Henry is taking his insulin as prescribed. His fasting BS is now 139 and he is exercising regularly.
Grace is a 50-year-old female with asthma, hypertension, chronic kidney disease, adrenal adenoma and uncontrolled type 2 diabetes mellitus (A1c 10.3%) on basal, bolus insulin.
Grace’s care team were on different EMRs making it difficult to collaborate on a shared care plan
Victoria, PharmD coordinated care between the endocrinologist and the PCP to develop a shared care plan to address Grace’s uncontrolled diabetes. Recommendations were placed for microalbumin which resulted in a referral to nephrology & ACE Inhibitor
Grace was identified as having limited social support and being a poor self reporter.
Victoria assisted Grace in obtaining a Freestyle Libre to consistently measure her BS. She met with her bi-weekly to titrate insulin and review proper administration technique
Grace’s A1C improved to 8%