Clinical Program Spotlight: A Care Management Success Story

December 6, 2018

At 62 years old, Medicare ACO patient, Dave, had a history of HTN, GERD, Cerebellar Atrophy, Ataxia, BPH, Obstructive Sleep Apnea, Hyperlipidemia and depression. Like many Medicare beneficiaries, he lived alone with no family and limited social support.

Dave was suffering in isolation, both physically and mentally. His depression prevented him from receiving the necessary care he required. He missed his medical appointments, stopped taking his medications and was no longer bathing or leaving his home.

Dave’s physician, Dr. Steven Carr, of Milton Primary Care, LLC, was concerned for his patient’s health. “Dave was not taking care of himself and although we scheduled appointments, he did not come in and he did not answer the phone,” explains Dr. Carr. In March of 2018, Dr. Carr contacted his NEQCA Care Manager, Lisa Quirk, to help intervene, with the goal of assessing Dave’s health status, goals and home care needs.

After not being able to reach the patient directly, Dr. Carr suggested Lisa contact Dave’s elderly neighbor, who was his Health Care Proxy and Power of Attorney. The neighbor convinced Dave to speak with Lisa over the phone. Over time, through weekly phone calls, Lisa was able earn Dave’s trust, complete a comprehensive assessment, provide disease management education and assist Dave to identify goals. Dave scored 23 on the PHQ-9 screen, indicating he was suffering with severe depression. Lisa referred Dave to Elder Services for home care assistance and provided ongoing telephone support to promote behavioral changes, improve medication adherence and reinforce the importance of following up with Dr. Carr and a behavioral health provider.

As a result of care management support, in collaboration with Dr. Carr, Dave began counseling for his depression. He started to take his medications as ordered; he began to take care of himself and made doctor’s appointments a priority. That summer, only a few months after starting to work with Lisa, Dave not only left his home, he went to three Red Sox games!

Dave was no longer the sick and isolated man he had been three months prior. As he sat in Fenway Park, he was just a 2018 Red Sox fan, amongst the 37,000 others surrounding him, proud to have come this far, and more than ready to see what great things were to come. 

*The patient’s name in this story was changed for confidentiality purposes


To learn more about how your practice could benefit from the support of NEQCA Care Managers, watch the video below!