By: Kim Kim, MSN, RN-CDCES, Registered Nurse Certified Diabetes Care and Education Specialist at SoNE HEALTH
Managing a chronic condition can feel overwhelming. For many patients, their care teams include their Primary Care Provider and disease specialist, and often more support is needed at home for their day-to-day health management and tasks of daily living.
This is where we shine. Our clinically integrated network works collaboratively to focus on population health and provides the needed support services that patients can access from the convenience of their home and from trusted healthcare team members.
A recent success with a patient highlights our spirit of collaboration. A patient enrolled in our Chronic Disease Management Program was experiencing unique circumstances that impacted their health. Over several months, I outreached over the phone and supported the patient with identifying wellness goals. We reviewed education on disease management, nutrition, exercise, stress management, medication adherence and daily monitoring. We discussed how to avoid complications, annual screenings and coordinated with their Primary Care Provider and other health care team members.
As we developed a rapport, the patient felt comfortable sharing symptoms, and I referred the patient to other members of our Population Health Team to address those needs outside of my skill set. Our pharmacy team was able to assist the patient with information on a medication option that was better tolerated, our social work team was able to assist with locating mental health services and support groups and another RN team member with expertise in an area of the patient’s medical history was able to provide resources for the patient. Together – we were able to assist the patient in accessing services and ultimately move forward with their wellness goals. The patient was so thankful to the team writing to our office to share their experience and encourage other patients to consider enrolling in our programs because of the full array of support received.
No one individual can take credit for this success, rather the sum of our parts made all the difference for this patient. Our core value of collaboration was truly exemplified with this patient success story. I consider myself very lucky to work with such caring, skilled, and knowledgeable teammates who share in our commitment to improve the lives of our patients and support them along their wellness journey. Together, we can do more for our patients.