Case managers for Community Care Plan of Eastern North Carolina give new meaning to the term “accessibility.” These case managers participate in Community Care’s medical home pilot for Medicaid patients with diabetes. Roberta Burgess, nurse case manager for the program, describes how case managers educate patients about their condition and prepare them for doctor’s visits:
“We build an ongoing relationship with the family. So many times people have been in their medical home for 20 years, they’ve been going forever and ever and that’s a good thing. We provide excellent education; we do this also in the practice. We also make telephone calls, we send out population management letters, information about community support groups, information about diabetes health fairs, different kinds of medicine. We go in their home and actually teach one on one. We find out what they know, what they don’t know, and where can we impact and help them grow. We teach them how to take care of their diabetes on a level that they can do it. As far as care coordination and case management strategies, we also do assessments. A lot of times they’re done at the doctor’s office, but we will often have a time where we can go in and do them in their home as well. And as care coordinators, as case managers, we contact that diabetic on a regular basis. And in my case, we contact our diabetics, the ones that are on our case ID, maybe every 2 or 3 months, just to talk to them and find out, ???How are you doing? Are you getting your medicine? Is anything going on? Have you had a cold? Did you get your flu shot? Any sores? Have you had your feet checked???? Just general conversation. When we call, they’re ready to talk, so a lot of times any time a new problem comes up we can go ahead and have it addressed, make an appointment and get them in and get them seen. And that’s a part of being accessible.”
The award-winning program, which saved North Carolina taxpayers $231 million in 2005 and 2006, develops diabetic resource tools for providers and has launched a diabetes education program that maximizes self-care behavior. This involves providing diabetes education and training to the client in their home.