A Breath of Fresh Air: Care Navigation Makes Specialized Care Possible
A Senior Care Action Network (SCAN) member recently encountered significant barriers after transitioning to a new Medicare Advantage (MA) plan. Confusion between provider offices caused repeated referral errors, preventing her from being scheduled at a specialized treatment center for urgent care needs.
A care navigator stepped in to help, working through multiple miscommunications and coordinating with the member’s primary care provider to ensure the correct referral and authorization were submitted. Once everything was in place, the member was finally able to get scheduled for the care she needed.
During a follow-up call, the member shared how grateful she was for her care navigator’s support, describing her as “a breath of fresh air.” She said the navigator always called back when promised, understood the system and made her feel like more than just another call. The member credited her care navigator’s persistence and coordination as the reason she was ultimately able to access the specialized care she needed.
Finding Control and Confidence Through RPM
A patient enrolled in the Remote Patient Monitoring (RPM) program to better manage her hypertension. At the time of enrollment, her readings were significantly elevated, and it became clear she had limited understanding of how hypertension — along with diet and medication adherence — was affecting her overall health and well-being. Living with hypertension had become her “new normal” and she lacked the tools and knowledge to make meaningful changes.
With guidance from her case manager (CM), the patient began building healthier habits and a stronger understanding of her condition. The CM supported her in adopting a low-sodium diet, taking medications consistently as prescribed and maintaining close coordination with her physician. Early on, she was slow to respond when her blood pressure reached concerning levels. Through ongoing education, she learned when to seek medical attention, as well as the long-term risks associated with uncontrolled hypertension, and practical ways to improve her readings.
The CM also played an important role in communication and care coordination by regularly sharing the patient’s vital sign readings with her primary care provider. This included sending updates ahead of scheduled visits as well as compiling monthly reports to ensure her care team stayed informed and aligned.
In addition to managing her blood pressure, the patient committed to improving her overall health through weight loss and increased physical activity. Over time, she began to see steady progress. Her blood pressure has decreased and continues moving closer to her goal range. She also reports that the frequent headaches she once experienced have resolved, greatly improving her daily quality of life.
The patient feels encouraged by the progress she’s made and more confident in her ability to manage her health. Reflecting on her experience, she expressed deep gratitude for the support she received, sharing that she would not have made these improvements on her own and had previously accepted living with uncontrolled hypertension.
Closing a Critical Wound-Care Gap
When an older adult client developed a diabetic wound that required home health wound care, an unexpected challenge threatened to delay treatment. The client's established provider was located out of state, and a new primary care appointment with a local provider was still weeks away. As the wait continued, the client's wife became increasingly concerned, reporting that the wound appeared to be worsening.
Recognizing the potential risk of delayed care, the transitional care nurse stepped in to coordinate support. With the client's permission, the nurse worked directly with the established provider, the clinical care team and the home health agency to secure the necessary wound-care orders. By bridging communication across multiple organizations, the nurse helped remove barriers that could have postponed services.
As a result, the required orders were obtained, and home health wound-care services could begin without waiting for the upcoming primary care appointment. This timely intervention helped address a significant care gap, supported continuity of care and reduced the risk of wound complications that could have led to an emergency department visit or hospitalization.
Through proactive care coordination and advocacy, the care management team ensured the client received the right care at the right time, helping prevent avoidable complications and supporting a safer recovery at home.
