Care in Action
When an 86-year-old patient from Denham Springs entered Ochsner Health Network’s Outpatient Care Management program, her medical picture was challenging. She was one of our most complex patients with elevated blood pressure and a history of stroke, heart failure, emphysema, and kidney disease. She also had multiple chronic conditions and two recent emergency department visits, both leading to inpatient stays.
That’s where our coordinated care team stepped in. Working closely with the patient’s primary care provider, Daniela Cardozo-Kellogg, MD, a team that included a dedicated registered nurse, social worker and community health worker developed a care plan that addressed both medical and social needs.
The care team’s interventions included:
- Enrolling the patient in Mom’s Meals for heart-healthy, low-sodium nutrition support
- Referring to pharmacy assistance and social work for medication and financial help
- Providing education on blood pressure monitoring, daily weight checks, recognizing stroke symptoms and fall prevention
- Supplying prescription coupons and connecting her to utility assistance and Ochsner financial support programs
- Assisting with a SNAP application to improve access to food
After just over three months in the High-Risk OPCM program, the patient’s results told a powerful story:
- Blood pressure down to 128/68
- Weight: stable
- Diet: following a heart-healthy, low-salt plan
- Financial health: improved, with SNAP, PAP and utility support in progress
- Acute care: zero inpatient admissions or ER visits since enrollment
This success reflects the strength of Ochsner’s clinically integrated, multidisciplinary approach in which physicians, nurses and care coordinators unite around the shared goal of improving health and preventing crisis care.
Have a patient story to share? Please email OHNadmin@ochsner.org with the details. If you would prefer to share the details with us over the phone, send your phone number and we will call you!