CARE MANAGEMENT PROGRAM ACCELERATION

After a hospital admission, I used Lightbeam’s cohorts to identify and contact a patient admitted to the hospital the day before. They had a history of gastroesophageal reflux disease (GERD), hypertension, vertigo, and reported metastatic colon cancer after colon resection. The patient went to the hospital due to significant weakness, fatigue, decreased intake of food and fluids, and difficulty performing basic activities. After their stay, the patient was discharged with home health in place. Unfortunately, the patient lived alone with no immediate family in the area and only one friend who would check in a few times a week. After determining the patient could not care for themself post-discharge due to increased weakness, I contacted them to create a care plan and complete a successful transition of care into their skilled nursing facility (SNF) of choice. The patient and their friend were very grateful for all the work we did to ensure a safe environment with access to care, and Lightbeam’s notification of admission accelerated what would have been a much longer process.

I was helping a high-risk patient after they were discharged from a stay in the hospital. The patient had a list of diagnoses, including type II diabetes, chronic kidney disease (CKD), chronic obstructive pulmonary disorder (COPD), coronary artery disease (CAD), multiple myeloma, arthritis, and anxiety. Using Lightbeam’s Care Management module, I created an individualized care plan and documented every service performed right in the patient’s profile. I called the patient and their spouse regularly every 3 to 4 weeks to check in. I learned that the patient’s spouse had difficulty determining the right foods to prepare for people that manage diabetes and renal problems. On top of that, the patient was having trouble swallowing. I discussed my proposed care plan with the patient’s physician, and they agreed that it was important to speak to a nutrition and diabetes education specialist. After learning helpful ideas for snacks and meals, the patient and their spouse feel more confident to manage their health at home and engage with me during follow-ups.

My particular role is to help patients and their families after discharge from hospitals or skilled nursing facilities. When I think about how much Lightbeam has helped me determine which patients need intervention the most, a particular situation comes to mind. Leveraging Lightbeam’s Care Management tools, my colleagues and I saw a patient in their 90s that was frequently admitted to the hospital. This patient’s only immediate family was their daughter, who lived out of state. I contacted the patient and their daughter and became their point of contact if they had any questions or concerns before going to the hospital automatically. The daughter called me daily, and we would review medications, help set up home health services, and eventually set up hospice care. I truly love being a care manager and impacting patients in positive ways like this, and Lightbeam simplifies the process greatly.