Living with multiple chronic conditions, Medicare beneficiary Carson Boone credits care management for getting his health back on track.
"I'm sorry, who is this?" 90-year-old Carson Boone replied to the voice on the other end of the line.
When Evolent Care Partners Care Advisor Heather Haygood first called Carson in the summer of 2020, she was just one more person in a dizzying procession of health care professionals to reach out following his hospitalization for a complete heart block. The 90-year-old Raleigh, North Carolina resident had undergone a cardiac pacemaker implant, and managing his recovery, along with other health ailments, had become all-consuming.
"I didn't know where they were coming from. I had home therapy, I had PT, I had occupational therapy," he said. "I was getting loaded up with disease problems and doctor visits. And it was just absolutely overwhelming."
Yet, as he came to understand the role of care management, he discovered that Heather wasn't just another voice on the phone. She was an invaluable resource to take the load off him, coordinate his care and help him learn to better manage his health problems.
Like many patients identified for ECP's care management programs, Carson has a long list of complex ailments, many of them interrelated. In addition to congestive heart failure, he has stage four chronic kidney disease, hypertension, obstructive sleep apnea and osteoarthritis, with bouts of severe knee pain. Carson was trying to manage his many therapies, primary care visits and appointments with four different specialists with limited social support. Even seemingly straightforward tasks, like finding a new CPAP machine for his sleep apnea, felt too complicated.
"He self-manages very well," Heather says. "He gets where he needs to go, but he is on his own, so consistent support is helpful."
Carson said his main goal was avoiding the need for dialysis. That meant holding back the progression of his chronic kidney disease. Heather educated Carson on the importance of checking his blood pressure and weight daily, to track the potential buildup of excess fluids.
Carson was having bloodwork taken more often than necessary to track his kidney function and anemia, so Heather coordinated his lab work with his hematology and nephrology practices to avoid duplication and to facilitate sharing of the results between specialists.
In the meantime, she didn't waste time helping Carson address his more immediate needs.
New CPAP machine? Check.
Hearing aids? Check.
Covid-19 Vaccine? Check.
More than a year since that first call, Carson has graduated from the care management program, having achieved the goals that he and Heather set together. He has been able to stay off dialysis, and he is tracking his weight and blood pressure every day. Once, after noticing that both were higher, he called his doctor, prompting a change in his diuretic prescription.
The experience has made Carson a true believer in the value of care management.
"I wouldn’t make it if I didn't have this support," he said. "You get worn out. You need somebody on your side. I feel fortunate to have Heather to help me navigate. She knows everything that’s going on with me."
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.
