A Path to Better Health
The PSW Care Management Team followed up with a patient who felt lost after visiting the Emergency Department for breathing problems and pneumonia. The Nurse Care Manager helped them by arranging a meeting with a Nurse Practitioner, refilling their medications, and enrolling them in the Remote Patient Monitoring program.
They also assisted the patient in finding a Primary Care Provider (PCP) despite their fear of doctors. Positive changes were facilitated, such as smoking less and accessing assistance from Medicaid and food banks. As a result, the patient remains enrolled in PSW services, regularly connects with their care team, and has a newly positive attitude towards improving their health.
Bridging the Gap to Recovery
During a weekly visit with one of our skilled nursing facility partners, PSW’s Care Management team helped a patient recovering from a hip fracture who was ready for discharge but lacked access to necessary durable medical equipment (DME). Due to the patient's rural location and financial constraints, purchasing the items out of pocket wasn’t possible, and online orders would delay discharge.
Using our ACO’s in-kind benefits, we purchased the needed DME from a nearby pharmacy, which was delivered the same day. The patient was able to go home the next day, avoiding a longer stay. A nurse care manager followed up that Monday to ensure continuity of care, and no gaps were identified. This seamless collaboration highlights our commitment to patient-centered care and timely transitions home.
Transforming Lives Through Care Management
When a patient was referred to PSW’s Care Management services, unmanaged anxiety and depression had led to frequent emergency department visits. Living alone, she struggled with daily tasks and had stopped taking her medications due to fear of allergic reactions.
Her nurse care manager provided compassionate guidance, educating her on medication safety and collaborating with her pharmacist and physician to ease concerns. With this support, she regained confidence in managing her health. She was also connected with behavioral health resources and began counseling, which she now attends consistently.
Encouraged to explore new activities, she started daily walks and joined a senior center, where she discovered a love for crafting and built new social connections.
Today, she feels healthier and happier—taking her medications as prescribed, engaging in her community, and no longer relying on the emergency department. Her journey is a testament to the life-changing impact of PSW’s Care Management.
