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Tracking Care Over Time Helps Avoid Serious Disability

When a visit to his physician at Intermountain Healthcare's Herefordshire Clinic revealed that B. Ward Turner had high blood sugar levels and a hemoglobin A1C of 10.9 (a test to assess diabetes control-the usual goal is a level less than 7), his physician wasted no time in referring him to Ann Larsen, a registered nurse care manager. Ward, who is now 84 years old, was at high risk for complications of diabetes due to a previous heart attack and multiple chronic health conditions, including congestive heart failure, arthritis, thyroid problems, and high cholesterol. Identifying and treating diabetes is critical, especially since close to 21 percent of Americans age 60 and over have diabetes, many of whom are not diagnosed.

In Salt Lake City, B. Ward Turner does water aerobics regularly as part of a comprehensive care plan to keep his diabetes under control.

Mr. Turner with his Care Manager Ann Larsen, RN, Certified Diabetes Educator. Ms. Larsen's participation in the inter-disciplinary team allows her to provide regular updates on Mr. Turner to his health care providers while helping Mr. Turner adjust to recommended changes in his treatment regimens.

Preventing diabetes complications such as kidney damage, loss of vision, and heart disease would require aggressive management of Ward's disease and the physician simply did not have time to properly educate him. This was almost ten years ago. Ann evaluated Ward for conditions such as fall risk, memory, and mood-all key factors that can impact his health and quality of life. She also invited him to attend a wellness clinic where she teaches the standards of diabetes care. Ward learned about the importance of cholesterol control and yearly foot and eye exams to check for changes. His health care team followed his progress with tools of Care Management Plus: the patient worksheet and the care manager tracking database.

With appropriate lifestyle changes, including water aerobics, meal planning, monitoring his blood sugar, and taking medication, Ward met his goal of controlling his diabetes. Over time, however, his blood sugar levels began to rise and Ward and his doctor decided to begin insulin therapy. Ann provided the training and coaching to help Ward learn how to administer insulin injections and she continues to monitor his progress, dealing also with his other conditions.

“Ann is a great partner,” says Ward. “I feel good and I'm happy with where I am.” For Ann, having the opportunity to help patients like Ward is the best job she's ever had. “My goal is to find out what the patient needs and get it in place,” says Ann.

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