Extending Relationships with Chronically-Ill Patients

Under MACRA/MIPS and the physician Fee Schedule, Medicare is demanding and paying clinicians for providing care outside of regular office visits. 3 out of the 4 MIPS performance categories and an additional 7 CPT codes in 2017 relate to providing care management.

Signallamp Health dedicates RNs to collaborate with physicians to monitor and help manage their most challenging and time-consuming patients.

In this series, Signallamp Health highlights the positive impact of its RN-driven, hands-on approach on patient care.Patient Overview
Demographics: 68 year-old female with Depression diagnosed after death of her husband.
Potential complications: suicide, heart disease, and health-jeopardizing behaviors such as smoking, substance abuse and eating disorders.

Disease Assessment
Depression is a leading cause of co-morbidities and injury. While effective treatments are available, many suffering from depression do not have access to treatment or take advantage of services.

Signallamp Health’s Approach
The physician diagnosed the patient’s depression soon after the death of her spouse. After pursuing a number of treatment options and believing that this patient needed more active monitoring, the physician chose to enroll this patient in Signallamp Health’s chronic care management program.

Linda, a registered nurse with Signallamp Health, reached out to the patient shortly after enrollment, and based on the documentation in the EMR, prepared to address the diagnosis of depression in incremental steps.

To learn more about Linda’s long-term, incremental approach to patient care, read more.

“When I first spoke with the patient, she had difficulty speaking about her depression,” said Linda. Linda learned that the patient found it extremely difficult to cope with the loss of her husband — especially around the holiday. This would be the first holiday without her husband. The patient struggled to find motivation to leave her home, telling Linda that she used to enjoy going shopping for gifts for her grandkids. The patient also complained of feeling tired all the time and believed it was from her medications. As a result, she stopped taking them.

Linda triaged the physician regarding the patient’s medication status, encouraged the patient to see the doctor and facilitated an appointment. Following the office visit, the patient decided to continue to take her medications as prescribed.

Through Linda’s ongoing conversations with the patient, it became apparent that the patient was now open to seeking professional mental health care. Communicating through the EMR, Linda informed the physician that the patient was open to therapy, and her physician provided a referral to a psychologist.

With the monthly calls, Linda was able to gain trust and build a relationship with the patient. Linda and the patient discussed the importance of getting involved in activities that are of interest to her. Linda commented: “The first thing my patient did was shopping for her grandchildren’s holiday gifts. She also made a few lunch dates with her friends and started an aerobics class at the local gym that I recommended. What my patient is happiest about is that she is spending more time with family, particularly her grandchildren, whom she just adores. She is finding enjoyment in things again,” said Linda.

Results
The patient’s mood has improved, and she is getting regular exercise and social interaction. She is beginning further treatment with a psychologist to help keep her life on a positive track.

What can you do as a clinician?
Does this sound like a patient that is under your care? Here are some suggestions to give your patients around the holidays, a time of the year when depression is more prevalent:

Begin a new holiday tradition.
Do not feel pressured to be at every holiday event. You are suffering through a lot of sadness, and your family and friends understand that. Be honest and tell them, “I am not up for this right now.”
Sign up to volunteer.
You can volunteer at a soup kitchen, a gift drive, the local holiday market. Helping others always has benefits for the griever too.

Get up and start moving.
Whether you go to a YMCA class, or even a walk. These things will help you feel more relaxed and feel better about yourself.


About Signallamp Health
Signallamp Health delivers a personalized approach to chronic care management. RNs are dedicated to your practice and collaborate with your care team to create one-on-one connections with patients outside of the office. Signallamp Health works seamlessly within your EMR (no integration required), provides care management services with RNs, and does so at no cost to the practice. Signallamp Health is good for your patients and good for your practice.

To learn more about Signallamp Health’s nurse-led care management services, connect with John Taylor at (610) 675-6887 or JohnT@signallamphealth.com. Find us online at www.signallamphealth.com.

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