There’s no surprise in hearing that our health care system has missed the mark in supporting some chronically ill patients.  Every year millions of patients with chronic conditions are undiagnosed, not receiving the appropriate follow up care or monitoring to prevent illness complications.  

It is estimated that in Texas approximately 460,040 people are living undiagnosed with diabetes and an additional 984,142 have pre-diabetes symptoms.[1] Good quality health care, patient education and family support for an illness like this can mean the difference between maintaining a high quality of life – and making regular visits to the emergency room. 

Care Improvement Plus is one of many health care organizations attempting to address this issue in the Rio Grande Valley. Through its Care Management program, Medicare members with chronic illness are connected with nurses that serve as their health resource and advocate.  Nurses follow up with members before and after physician visits, keep an eye on prescribed medications to ensure there are no contraindications– and communicate with member physicians whenever health risks are identified.  The goal of Care Management programs are not only to educate members on disease problems and options, but to also provide much needed support to the family, facilitate family and member goals, and avoid unnecessary hospitalizations. 

One of the most critical and important benefits of the Care Improvement Plus program is the post- hospital discharge consultations with members.   Within days of discharge, a nurse will reach out to a member in an effort to ensure they have a clear understanding of home care instructions, have necessary prescribed medications, and the support they need to ensure a speedy recovery and prevent readmission. 

In the past, nurses have arranged free transportation for members to see their doctor, located physicians for specialized services and set up appointments, and provided health advice on how to lead healthier lives.  It is this aspect of coordination of care that so many chronically ill seniors in the Rio Grande Valley don’t receive to maintain their health.

[1] Statistics compiled from the CDC Behavioral Risk Factor Surveillance System – Prevalence Data 2009, and the Texas Department of State Health Services 2011.