The Heart of Care: Beating the Odds with Compassionate Care Coordination

May 11, 2020

Evolent RN Care Advisor Sandi Massey was worried about "John." For a month after he was discharged from the hospital, she had regularly checked in on him to ensure he was receiving all needed post-discharge care. Yet, as his 30-day Transition Care program ended, John was having trouble affording his medications. On top of that, he'd recently learned several of his family members had tested positive for COVID-19. While John confirmed he hadn't been in recent contact with them, John was still recovering from a respiratory condition, and Sandi had concerns about graduating him from the program.

"With everything going on in this patient's life, I didn't feel comfortable closing the case just yet," Sandi explained.

Sandi referred John to RN Care Advisor April Womack, for further outreach as a part of Evolent's Complex Care program for individuals with multiple chronic diseases. When April spoke to him, he was experiencing extreme shortness of breath. April worked with him to schedule a virtual appointment with his pulmonologist and get in touch with the pharmacy about the medication he needed to breathe more easily. 

During the telehealth appointment, John confirmed that he was still having trouble affording his prescribed medication. Hearing that, the pulmonologist delivered samples of the medication to the member's house so that he could safely remain at home in self-isolation. The pulmonologist also conducted a verbal COVID-19 screening and after determining that he was likely positive for COVID-19, she provided education to him on safe at-home treatment.

"The way Case Management and Pulmonology teams came together for this patient really stood out to me," April recalled. "It just goes to show that with the right care and compassion, we can really do a lot in health care." 

April has continued to follow up with this member on a weekly basis, and he's improving every day. Each time they speak, he's able to go longer stretches without having to stop for breath.

"The odds were stacked against him with this virus, but he is doing remarkably well," April said.

Both Sandi and April acknowledge that COVID-19 has uncovered some long-term focus areas for health care professionals, but they're already identifying some solutions to carry forward.

"We're going to have to deal with the effects of isolation more and more," Sandi predicts, "but I'm finding that spending a little extra time with members, looking for hotline numbers or resources can really make them feel like there's a lifeline out there."

As for April, working closely with patients and colleagues during a global health crisis has brought some personal and professional encouragement.

"This pandemic has renewed my sense of compassion," April remarked. "Health care segments are coming together, closer than we ever have before. That's something I'll never forget."

About The Heart of Care
Every day, members of Evolent's care management teams use their clinical expertise and problem-solving skills to help individuals overcome serious health challenges. The Heart of Care series tells stories from the field that highlight their dedication to patients. For more information, see the blog post by Evolent CEO Frank Williams.
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