Catherine Jenkins is a 70-year-old retired high school guidance counselor. She is single and lives alone in her home with her dog. She receives social security checks, a small pension, and Medicare with basic coverage for medication. She has a son who is married with two teenage daughters, and lives about 25 miles away. Ms. Jenkins has four chronic conditions: hypertension, diabetes, heart failure, and rheumatoid arthritis. She sees six different physicians for these conditions and takes eight medications.
In 2012, Ms. Jenkins, had a difficult year. She had several exacerbations of her conditions, including four hospitalizations for her heart failure and hypertension. Her diabetes became less controlled and she has increased pain from her rheumatoid arthritis. She has spent time in two nursing homes and received home are from two different agencies with referrals to six different community agencies for assistance at home.
Ms. Jenkins is confused about her medications. She does not understand her diabetic diet and does not monitor her blood pressure. She describes her quality of life as poor. Her son dreads calls from her, as well as many providers and agencies involved in her care. He has no idea what to do about all the bills, the different doctors, and the different appointments. At this point, he is ready to put his mother in a nursing home. He cannot handle managing her care and is fearful for her safety.
This is a common story that is told by many individuals and their families across the nation.
Header 1 of paper: How can you use the one of the care coordination models to guide you in developing, measuring, and evaluating a coordinated care plan for Ms. Jenkins and her family?
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