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Feature Article Coordinated Care Guides Lebanon Woman to Better Health

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Tamara Edwards was diagnosed with congestive heart failure six years ago after being rushed to the Emergency Department and spending 10 days in the hospital.

“It felt like I had an elephant sitting on my chest,” the Lebanon woman recalled.

Doctors placed two stents in her heart to stabilize her condition. She’s had to make many trips to the hospital since then to remove excess fluid that built up around her heart, making it hard to breathe. Her condition is more complex because she also has diabetes. But lately, Edwards has had better control of her symptoms, thanks to coordinated care provided by Samaritan Health Services.

In this new model, patients receive ongoing guidance to help them manage their conditions. In addition to seeing a primary care doctor and cardiologist for regular problems, a pharmacist, nursing assistant, physician assistant and diabetes educator are available.

“It makes things less stressful, because I know I can get answers,” Edwards said.

She added that she also likes the convenience of her MyChart electronic health record to communicate with her care team.

“I can shoot a quick note off to them and they’ll tell me what I need to do,” she said.

Improved communication identifies barriers that keep patients from following a care plan – like not being able to read a prescription bottle, not having enough money for prescription co-pays, or needing help with preparing healthy meals.

Tanya Grant, Samaritan’s care management director, said they have already reduced hospital readmission rates for patients with congestive heart failure by 35 percent. And patients report experiencing a better quality of life.

“It is the difference between being able to do the things they want and having to come back to the hospital,” Grant said.