Care management gives healthcare professionals an opportunity to build lasting relationships with patients, improve chronic disease management, and address the everyday barriers that can prevent people from receiving the care they need.
In an episode of the CareCoordinated Podcast by ThoroughCare, Dan Godla speaks with Kathryn Anderton, BSN, RN, BC-RN, CCM, VP of Clinical Services at ThoroughCare, alongside clinical team members Margaret Mihalis, RN, Clinical Onboarding Manager, and Maranda Cruce, RN, BSN, CCM, POMP, Manager of Clinical Operations. The team shares how their nursing backgrounds shaped their approach to care management, why patient engagement is essential to better outcomes, and how personalized support can help patients take control of their health.
Their experiences highlight an important distinction between traditional acute care and ongoing care management: successful care management goes beyond identifying a patient's medical needs to understanding what matters to the patient, what barriers they face, and how their care team can help them succeed.
What Is Care Management?
Care management is a coordinated, patient-centered approach to healthcare that helps individuals manage their health conditions, navigate healthcare services, and access the resources they need between appointments.
For patients with chronic conditions, care management can provide ongoing support with medication adherence, self-management education, care coordination, and communication with healthcare providers.
Programs such as Chronic Care Management (CCM) help eligible patients receive continued support outside traditional office visits. Rather than focusing only on an immediate medical concern, care managers can work with patients to establish goals, monitor progress, coordinate resources, and address barriers that affect their ability to follow a care plan.
As the ThoroughCare clinical team explains, this approach also creates opportunities for nurses and other healthcare professionals to use their clinical knowledge in a more proactive, relationship-focused setting.
1. Moving From Bedside Nursing to Care Management
For many healthcare professionals, a transition into care management begins with a desire to make a more lasting impact on patients.
Maranda Cruce began her nursing career in the operating room before moving into orthopedic and trauma care and eventually occupational health. Margaret Mihalis spent eight years in nursing, beginning on a cardiac and stroke step-down unit. Kathryn Anderton also worked in a small clinic and an acute care setting, including a stroke step-down unit.
Their experiences gave them valuable clinical skills, but they also exposed the limitations of delivering care in fast-paced environments.
The challenges of acute care
Hospital nurses frequently work under significant time constraints, particularly when staffing shortages and competing clinical priorities limit the time available for patient education.
Margaret Mihalis describes how these challenges became especially apparent during the COVID-19 pandemic. Patient education and discharge planning could feel rushed, leaving limited time to explain what patients needed to do at home to manage their health and avoid returning to the hospital.
Maranda Cruce shared a similar experience. In acute care, clinicians often have to address the most immediate medical needs, even when they recognize that patients would benefit from additional education and support.
Care management offers another way to apply that knowledge.
A more proactive approach to patient care
Instead of concentrating primarily on an acute episode, care managers can work with patients over time to support long-term health goals.
This ongoing relationship creates opportunities to:
- Reinforce patient education after an office visit or hospital discharge.
- Help patients understand their medications and chronic conditions.
- Identify barriers that interfere with treatment plans.
- Coordinate appointments, services, and community resources.
- Encourage patients to participate in their own care.
- Communicate changes and concerns to the appropriate healthcare providers.
For nurses considering a career in care management, these responsibilities provide a way to build on existing clinical experience while emphasizing prevention, education, and continuity of care.
2. Building Trust Is Essential to Patient Engagement
Patient engagement is one of the most important skills in effective care management. Patients are more likely to participate in their care when they feel heard, respected, and understood.
According to the ThoroughCare clinical team, relationship-building is not simply a pleasant addition to care management. It helps create the trust necessary for meaningful conversations about health, personal challenges, and treatment goals.
Margaret Mihalis emphasizes the importance of establishing rapport so patients are more receptive to education and self-management guidance.
In contrast, a rushed interaction can make a patient feel as though they are completing a checklist rather than working with someone who understands their needs.
Ask patients what matters to them
Maranda Cruce explains that care managers sometimes become the first healthcare professionals to ask patients a question that goes beyond their symptoms: What matters to you?
A patient's priorities can influence whether a care plan is realistic and sustainable. Understanding those priorities helps care managers connect health recommendations with the patient's everyday life.
For example, a patient may understand the importance of following a recommended diet but struggle to change family food traditions. Another patient may know they need a follow-up appointment but lack reliable transportation.
Without understanding these circumstances, a care manager may see a patient who appears disengaged. With the right questions, the care manager can identify an opportunity to provide practical support.
Make conversations personal
The team recommends moving beyond routine questions about symptoms and treatment adherence.
Asking patients how they are feeling, what is happening in their lives, and whether anything has changed since the last conversation can reveal information that affects their health.
Remembering details from previous interactions also helps reinforce the relationship. When a care manager follows up on a concern a patient previously shared, the patient can see that the conversation was meaningful and that their experience matters.
The goal of patient engagement is not simply to get patients to answer the phone. It is to build a relationship in which they feel comfortable sharing their needs and participating in their care.
3. Use Motivational Interviewing to Improve Patient Engagement
Motivational interviewing is a communication approach that emphasizes listening, open-ended questions, empathy, and an understanding of a person's own motivations for change.
Kathryn Anderton describes how this approach can make care management conversations more effective.
If a care manager focuses only on directing the conversation toward predetermined clinical goals, a patient may feel that their concerns are being overlooked. By giving patients room to explain their experiences, care managers can better understand what motivates them and where they need help.
Practical patient engagement strategies
The ThoroughCare team highlights several techniques care managers can use to build stronger patient relationships.
Ask open-ended questions. Questions that invite a detailed response can reveal more than a simple yes-or-no answer. Instead of asking only whether a patient is taking medication, a care manager might ask what makes it easier or harder to take medication consistently.
Listen more than you speak. Allowing patients to explain their experiences can uncover concerns that might otherwise remain hidden.
Approach conversations without judgment. Patients may feel embarrassed about missed appointments, medication challenges, or difficulties following recommendations. A supportive conversation can make it easier for them to share the underlying problem.
Explore the reasons behind behavior. A missed appointment or an unmanaged condition does not necessarily mean a patient is unwilling to participate in their care. The patient may face financial, transportation, social, or other practical barriers.
Connect recommendations to personal goals. Understanding what matters to a patient helps care managers develop realistic next steps that fit the patient's circumstances.
These strategies help transform care management from a series of check-ins into a collaborative process focused on the patient's needs.
4. Address Social Determinants of Health and Barriers to Care
Social determinants of health are the conditions in which people live and the circumstances that influence their health and access to care. In the podcast, the clinical team discusses how factors such as transportation, food access, medication affordability, and social support can affect a patient's ability to manage a chronic condition.
One of the central lessons from their experiences is that healthcare professionals must understand the reasons behind a patient's actions before determining how best to help.
Medication adherence may depend on access
Maranda Cruce recalls working with patients who did not take their medications consistently because they lacked a reliable way to obtain them.
In some cases, coordinating home delivery of medications helped remove that obstacle. The problem was not necessarily a lack of understanding about the importance of treatment. It was a practical barrier that the care team could help address.
Transportation can affect follow-up care
Patients may miss medical appointments because they do not have a ride. Care managers can help identify transportation resources and coordinate support so patients have a better opportunity to attend appointments.
Food access can influence recovery
After a hospital discharge, patients may return home without groceries or the resources needed to prepare appropriate meals. Cruce describes situations in which care teams arranged meal delivery to help patients manage this transition.
Medical equipment and education can support self-management
Care managers can also help patients obtain necessary equipment and understand how to use it. Access to a blood pressure monitor or blood glucose meter, combined with education about monitoring results, can help patients participate more actively in managing their conditions.
These examples illustrate why patient-centered care requires more than identifying a diagnosis and recommending a treatment plan.
Care managers need to understand whether patients have the resources, support, and practical ability to follow that plan.
5. Real-World Example: Helping a Patient Manage Diabetes and High Blood Pressure
One of the most compelling stories from the podcast demonstrates how ongoing care management can help a patient address multiple health challenges.
Margaret Mihalis recalls an initial outreach call with a patient who was hesitant to participate and initially suspected the call was a scam. After establishing trust, she completed an initial assessment that revealed several concerns:
- The patient's diabetes was severely unmanaged.
- His blood pressure was uncontrolled.
- He was experiencing medication adherence challenges.
- He needed assistance accessing food resources.
Rather than ending the conversation with general recommendations, Mihalis worked to coordinate practical support.
The patient received a blood pressure monitor and a blood glucose meter. During subsequent conversations, she explained how to monitor and log readings and how to recognize elevated blood pressure and blood glucose levels.
Over approximately six months, the care management relationship helped identify continued blood pressure concerns and create an opportunity to coordinate further care with the provider.
Mihalis helped arrange a provider appointment to discuss the patient's progress and the need to reassess his treatment approach. She reported seeing improved patient outcomes over that period.
The patient eventually expressed appreciation for the time and attention invested in his health.
Why this example matters
This story highlights several important elements of effective chronic care management:
- Build trust before expecting engagement. The initial hesitation did not prevent the care manager from developing a productive relationship.
- Identify multiple needs. The assessment revealed clinical concerns as well as a need for food resources.
- Provide practical support. Equipment and education gave the patient tools to monitor his health.
- Maintain consistent follow-up. Continued conversations helped the care manager identify ongoing concerns.
- Coordinate with the provider. Sharing information and arranging follow-up supported further clinical evaluation.
- Build patient confidence. The goal was not simply to monitor the patient but to help him better understand and manage his health.
The example shows how personalized care management can connect clinical knowledge with the everyday support patients need to make progress.
6. Why Post-Discharge Care Coordination Matters
The transition from hospital to home can be a vulnerable period for patients. They may have new medications, additional appointments, changes to their daily routines, and instructions they must follow while recovering.
Kathryn Anderton emphasizes the importance of the first several days after discharge, noting that patients may need more than an assessment of their medical needs.
They may also need assistance identifying and accessing the resources that make a care plan possible.
Care managers can help patients navigate this transition by:
- Reviewing medication and follow-up needs.
- Coordinating appointments with healthcare providers.
- Identifying transportation and food resources.
- Helping patients obtain durable medical equipment when needed.
- Reinforcing education about chronic conditions.
- Communicating concerns to the appropriate members of the care team.
Effective transitional support also requires understanding the patient's home environment and support system.
A patient may need to navigate stairs, live alone, have limited access to transportation, or lack someone who can help with daily activities. Understanding these circumstances can help the care team identify risks and coordinate appropriate assistance.
Care management helps bridge the gap between the instructions patients receive during a medical encounter and the realities they face when they return home.
7. What Skills Make a Successful Care Manager?
The experiences shared by Kathryn Anderton, Margaret Mihalis, and Maranda Cruce point to several characteristics that can help healthcare professionals succeed in care management.
Empathy
Patients may struggle to follow recommendations for reasons that are not immediately apparent. Empathy helps care managers approach these situations with curiosity rather than blame.
Communication and active listening
Care managers need to ask useful questions, listen carefully, and give patients opportunities to explain their concerns.
Curiosity
A successful care manager seeks to understand why a patient is experiencing difficulty rather than assuming the reason.
For example, if a patient struggles to change their diet, the care manager can explore the role of family traditions, food availability, personal preferences, and other circumstances before discussing potential changes.
Relationship-building
Trust can develop over time through consistent communication, remembering patient concerns, and following through on commitments.
Clinical knowledge
Nursing and other clinical experience can help care managers recognize health concerns, reinforce patient education, and identify when provider involvement may be necessary.
Resource coordination
Care managers need to identify relevant community resources and help patients navigate access to services, equipment, transportation, and other support.
A patient-centered mindset
The most effective care plans account for the patient's priorities and circumstances. Recommendations are more useful when they are realistic and connected to goals that matter to the individual.
Together, these skills help care managers support patients beyond the clinical encounter and contribute to more coordinated, personalized care.
8. How Chronic Care Management Supports Long-Term Patient Relationships
Chronic Care Management (CCM) provides a structured way for healthcare organizations to support eligible patients with multiple chronic conditions between office visits.
Ongoing care management can create opportunities for regular communication, patient education, coordination with healthcare providers, and support for individualized care goals.
The podcast discussion illustrates why these relationships matter. Patients may need help understanding their conditions, recognizing changes in their health, accessing resources, or overcoming obstacles to following a care plan.
When care managers have a consistent process for assessing needs, following up with patients, and coordinating services, they can help healthcare teams maintain a more complete picture of the patient's experience outside the clinic.
Technology can support these workflows by helping care teams organize patient information, document interactions, manage care plans, and coordinate follow-up activities.
ThoroughCare provides leading care coordination software designed to help healthcare organizations manage care management programs and streamline clinical workflows. Its platform supports organizations working to improve patient engagement, care coordination, and the delivery of value-based care programs.
The underlying principle remains the same: technology can help organize care management, but meaningful patient relationships depend on listening, trust, and a willingness to understand each patient's individual needs.
Frequently Asked Questions About Care Management
What does a care manager do?
A care manager helps patients navigate healthcare services, manage chronic conditions, understand their care plans, and access resources that support their health. Responsibilities may include patient assessments, ongoing follow-up, care coordination, education, and communication with healthcare providers.
How is care management different from bedside nursing?
Bedside nursing generally focuses on assessing and treating patients during a clinical encounter or hospital stay. Care management emphasizes ongoing support, care coordination, patient education, and long-term health goals beyond a single encounter.
What skills are important for a care manager?
Important skills include empathy, active listening, communication, clinical knowledge, relationship-building, resource coordination, and the ability to identify barriers to care. Motivational interviewing techniques and open-ended questions can also help care managers engage patients.
How can care managers improve patient engagement?
Care managers can improve engagement by building trust, asking patients what matters to them, using open-ended questions, listening without judgment, following up on previous concerns, and helping patients overcome barriers that interfere with their care.
What role do social determinants of health play in care management?
Factors such as transportation, food access, medication affordability, and social support can influence whether patients can follow their care plans. Care managers can help identify these barriers and coordinate appropriate resources.
How does Chronic Care Management help patients with chronic conditions?
Chronic Care Management provides ongoing support for eligible patients with multiple chronic conditions. Depending on the patient's needs, care management may include regular communication, care coordination, education, monitoring, and assistance with individualized health goals.
Can nurses transition into care management?
Yes. Nursing experience can provide a strong foundation for care management because it develops clinical knowledge, communication skills, patient education experience, and an understanding of healthcare workflows. The role may appeal to nurses who want to focus more on prevention, ongoing patient relationships, and coordination of care.
Learn More About Care Coordination With ThoroughCare
Effective care management starts with understanding the patient, not just the diagnosis.
As the ThoroughCare clinical team explains, building trust, asking thoughtful questions, addressing social determinants of health, and coordinating practical resources can help patients become more confident participants in their care.
For healthcare organizations looking to strengthen their care management workflows, ThoroughCare offers care coordination software designed to support patient engagement and the management of care management programs.
Full CareCoordinated Podcast Transcript: Being a Care Manager
The following transcript has been lightly edited for readability. Filler words, false starts, unnecessary repetition, and conversational interruptions have been removed while preserving the substance and meaning of the original discussion.
Dan Godla
Hey, everyone! My name is Dan Godla and welcome to the CareCoordinated Podcast. On today's episode, we'll be talking about being a care manager with Kathryn Anderton, our VP of Clinical Operations here at ThoroughCare. Kathryn, welcome to the podcast.
Kathryn Anderton
Thank you so much for having me. I'm so excited to be here.
Dan Godla
We're going to share an interview that happened with you and other members of the Clinical Advisory team here at ThoroughCare.
Kathryn Anderton
Yes. I'm so excited.
It was a great opportunity to talk through some of the things that led to care management, as well as some of the challenges we had in our previous roles. And what's really interesting is we all have our own unique experiences that got us here.
So it led to a really fruitful conversation, and hopefully some of the viewers can learn some of the positive impacts that we've had on patients and take the information into their day to day.
Dan Godla
That sounds great, Kathryn. Thank you. So if anyone out there is considering a career in care management, or perhaps you already work in the healthcare space, I think you'll find this discussion helpful.
So let's jump in.
Margaret Mihalis — 00:01:04
I'm Margaret Mihalis, and I'm the Manager of Clinical Onboarding here at ThoroughCare.
Maranda Cruce
I'm Maranda Cruze and I am the Manager of Clinical Operations here at ThoroughCare.
Kathryn Anderton
Maranda, I'd love to learn more, a little bit about your experience before care management, what you were doing?
Maranda Cruce
Sure. So when I started my nursing career after getting out of college, my first job was in the operating room.
Loved it. It was really exciting to work with patients in such a vulnerable stage in their lives. And then I'm transitioned out of the operating room and ended up being on the floor with orthopedic and trauma. I eventually worked in the occupational health space, and that was my final position before I entered the care management space.
Kathryn Anderton
And I know, Margaret, you have some acute care experience as well.
Can you tell us a bit about what you were doing prior to care management?
Margaret Mihalis
So I've been a nurse for eight years, and my first role was bedside on a cardiac and stroke step down unit.
Maranda Cruce
Kathryn, I'd love to hear what your background is in nursing.
Kathryn Anderton
My background is a little all over the place, so when I started out right out of nursing school, I had a job at a small clinic, which was kind of fun because I think in a lot of health care settings, if it's smaller, that doesn't mean your role is the same.
It just means you wear a lot of other hats still, maybe without necessarily the title. Then working in an acute care setting similar to you, Margaret, on a stroke step down unit. I very much felt the burnout of the pandemic, realizing that there was a lot out of my hands in the care that I really wanted to provide.
It was a great moment to kind of step back. Figure out work-life balance. What is it that I want out of a career? What's bringing me joy? And I found a lot of value in being able to connect with patients outside of that acute stay and build that relationship. That's something that's really important to me. I really value having that kind of connection, especially with patients.
And I think that translates to more effective care management almost. In your time spent at the bedside, I think we all have our own experiences of maybe what we didn't love in a hospital or facility setting, providing patient care. I'm curious, while there's benefits being there for patients at that kind of pivotal moment. What were some of the challenges you felt like in a role in the hospital?
Margaret Mihalis
I would say the biggest challenge for me was working throughout the pandemic and the hospital consistently being short staffed and in turn made everything that I was doing, all of my patient care, education, felt really rushed. Sometimes there wasn't enough time to sit down with a patient who was being discharged to say, hey, look, this is why you were here at the hospital.
Here are the things you need to do at home to manage your health better so that you don't come back to the hospital.
Maranda Cruce
I can completely empathize with that. That was a hard time as well, working bedside through the pandemic, and I remember hours being exhausted, like you were in for a 12 hour shift, but you'd end up staying for a 16 or you're in for an eight in year to 12.
And that burnout was really common during that time. One of the things that I find with bedside nursing is that you're kind of treating patients in what I would say is just like a moment of time for them. And what I like about care management is that you actually get to treat the patient more proactively and think of their their life long term, instead of in the hospital at bedside,
you're just trying to approach them at where they are right now and try to treat them in what's in front of you, versus thinking that long term and trying to set them up for success in the future. And something that you said, Margaret, about being able to have the time to educate patients. We have all this knowledge and as a nurse at the bedside, that's what you want to do.
You want to help prevent them from coming back in the hospital. And I agree, it was something that was lacking for me as well of like, I want to be able to share this knowledge, set them up for success when they're leaving and discharging and giving them that education. But oftentimes the time is lacking. You don't have the capacity to provide all of that education to patients.
And to your point, with care management, that's kind of where that skill set gets to thrive.
Kathryn Anderton
Definitely. And doesn't feel like I'm killing my body trying to move a patient by myself. I think we all can remember that. Short staff to call lights on. Someone's going for an MRI. It feels a lot easier to balance work as well as personal while giving the best to both.
Maranda Cruce
Yeah, I think part of something that I struggled with was feeling like I made a big enough impact on patients, because I remember feeling in the hospital at times, there was so much more I wish I could have done to help patients. But there was, just, like you said, either lack of resources, lack of time, other urgent matters coming up that prevented me from feeling like, oh, I spent as much time as I wanted to in everything that I wanted to educate the patient on and provide them with was was up to my standards.
Kathryn Anderton
What's the experience that you think makes for an ideal care manager?
Margaret Mihalis
I would say someone looking to build relationships and establish that trust with their patients so that they have that rapport. The patients more likely to kind of hone in on what you're saying, the education you're providing, the self-management tips. In a hospital setting, I think that you're so rushed, maybe from being short staffed.
You know, the nurse to patient ratio is not balanced.
Kathryn Anderton
Yeah.
Margaret Mihalis
You don't really have that time to build that rapport with your patient and establish trust.
Kathryn Anderton
It can almost feel cold when you go in. Quick assessment. Here's your meds. Okay. I just have five other patients I have to see right now. Where to be able to call them.
Follow up on their dog Lucy that they mentioned the last time. Those little things. How, Maranda, it feels like the inpatient surgery component and going over a lot of that discharge information that I imagine really strengthened your ability to support patients in those transitions at home.
Maranda Cruce
Yeah, definitely. I would say that that experience definitely did help for things that you have to be mindful of when you're working in care management.
So it's not just a matter of, oh, here are your meds, these are your restrictions, but there's a whole other piece that you need to consider when it comes to patients that are going home. You know, what is their lifestyle like? What is their home environment like? How many steps or things do they have access to that might prevent them from optimal recovery when they get home?
Who is in their support system? Like all of those things that you're able to better assess in care management and have the time for, instead of in the bedside, where it's more of a checklist of did they pass PT? Could they put their shoes on, you know? Did they pee before they were able to discharge? And so then it's like, okay, great on your way.
But when you're able to connect with them, like you said, building that relationship, getting to understand the patient better on a more personal level really helps impact their care in a positive way.
Kathryn Anderton
What are some of the tips and tricks that you guys have learned in your nursing career? That really helps your ability to engage with patients? It's an elective program I've heard from so many care managers, sometimes it feels like they're cold calling or having to do this sales pitch.
So I'm curious how you guys have found success in building this relationship with patients, connecting, making sure they answer your calls?
Maranda Cruce
I think a big thing for me is and what I found through care management is sometimes the care manager is the first person that actually asks the patient what matters to you. And because most of the time when you're in the hospital or you're seeing a doctor, it's more of a what are your symptoms?
And as much as those questions matter, what matters most is finding out what is important to the patient, because that's going to drive why they do things and and ultimately enhance their care and help them reach their goals moving forward.
Margaret Mihalis
Agreed and I think care management really gives us the opportunity to look at the patient from a holistic view and really personalizing that care.
We're not just calling them and going through a checklist. We're asking them, how are you feeling today? What's going on in your life? And then when we're following up on our assessments and our follow up calls with these patients. Being able to kind of recall, hey, I know last time we spoke you weren't feeling great. And it makes them feel like they aren't just part of a checklist, but rather they do have someone that cares about their outcomes.
Maranda Cruce
I love what you said. You you said, what's going on in your life? That to me is what you're saying about relationship building. It's not just a what's going on in your health. Because as we know, there's so many other aspects of people, patient's lives that impact their health. So I loved how you phrase that, what's going on in your life?
Because maybe their health is doing okay, but maybe they had a family member pass away or someone moved. And now that impacts their everyday life. That can, you know, impact their mental state. It can impact the resources that they have to support them. All of that, I think is key to keeping them engaged and making sure that they feel supported and heard and understood.
Maranda Cruce
Kathryn, I'm curious what what tools you use to help with engagement?
Kathryn Anderton
As you guys are talking, all I'm hearing, like all I'm thinking is yes, yes, like a motivational interviewing approach. It almost feels like everyone should practice a little motivational interviewing, because it's a way that, yes, we want to steer the conversation, but if we're not focused on what's important to the patient, eventually the patient's going to feel like we're just steering them to what we want to talk about.
They don't feel as seen or as cared for. And that's such a great point. Things can happen in their lives that dramatically impact their ability to manage health. And personally, you get the best tidbits when you have someone talking. You get the, they end up communicating their own why or where they're struggling. I think that's my number one is always focus on a personal element, because that's when you have a lot more meaningful clinical conversation.
When a patient feels more comfortable, they're more vulnerable. And it's easy to feel things like judgment, like shame and all of these things. So when you can neutralize it and come at it from partners without judgment. But we're just here trying to navigate the in-between successfully. It leads to, I think, a more successful relationship for sure.
Maranda Cruce
Agreed. And I think it's one of the skills I find in most successful care managers is their ability to listen, that oftentimes in care management, the care manager should ideally do less of the talking and allow the patient to do the majority of the talking.
Kathryn Anderton
Yeah.
Margaret Mihalis
And that's where the open ended questions come into play. We're not just asking them questions so they can say a quick yes, no, zero out of ten. We want to know more. We want to know the details. And I think sometimes patients don't quite know what details to offer. So when we start asking those open ended questions, we're going to learn a lot more.
Kathryn Anderton
So I know we kind of talked about how we didn't get to leave the mark that we wanted to in the acute care setting. I'd love to learn about a time where you did make a really positive impact on the patient.
Margaret Mihalis
Yeah. So I distinctly remember I had a patient that I called first. He thought that I was a scammer.
And so I explained to him....
Kathryn Anderton
You have to prove that that you know them, but you also can't tell them their own PHI.
Margaret Mihalis
Like, sir, if you can just tell me your first and last name and date of birth, I'm prepared to share a wealth of knowledge.
Kathryn Anderton
That’s what they all say.
Margaret Mihalis
So he thought I was a scammer. We got past that.
He was very hesitant to even complete an initial assessment with me and I let him know, hey, I need to know where you're at with your health now so that we can take next steps together. And so through the assessment, we found that his diabetes was severely unmanaged. His blood pressure was not controlled. He had issues with medication adherence.
He needed food resources. And so after that first call, I took the time to coordinate those resources for him. We got him set up with a blood pressure monitor as well as a glucometer. And the next month when I called him, he said, hey, I got all of the stuff that you sent in the mail. This is really great.
Now what do I do? So okay, next steps. We're going to start checking and logging your blood pressure every day. This is what a high blood pressure looks like. This is what a high blood sugar looks like. All of the things that I'm sure have been told to him by maybe a provider previously, but never, maybe quite sunk in.
So between coordinating things like DME or devices, setting him up with better nutritional information, and just giving him the confidence to kind of take his own health into his own hands, I would say about six months later, we started to see some real improvements. We saw that the blood pressure is were consistently high. Okay, so now I'm able to coordinate care with the provider and say this medications aren't working, a low salt diet isn't working.
What's next? I help him coordinate that provider appointment and really saw improved patient outcomes after about six months. And he at the end was kind of apologetic for the way that he talked to me on the first call. He's like, I know I was like, not into this. I was cutting you off. But thank you so much for taking the time and investing in me and my health.
Like I really appreciated it.
Kathryn Anderton
That's amazing.
Margaret Mihalis
I’ll never forget him.
Kathryn Anderton
I feel like that's the exact patient that you would say, are you having any symptoms right now? And they would say no, but that's because their blood sugars high 100% of the time.
Maranda Cruce
That is their normal.
Kathryn Anderton
It's their baseline. And so I almost would imagine that it's an opportunity to show someone what it feels like to be at a baseline
and when it's different. Those little changes that they probably don't even realize anymore.
Maranda Cruce
Yeah. I love, that's such a great example. And looking at like seeing a patient from almost start to what I would say, like finish and like graduate a program so that they have the confidence, like you said, to manage their care on their own.
I think some of my examples are more in the smaller things like, which might not seem like they have a big impact, but they do make a difference in the patient's lives. I remember having several patients that they appeared to be noncompliant, but when you got to know them, build that report, you really just learned that it was a lack of resources.
So some of them was they weren't taking their medications because they didn't have a way to go get them. And so being able to set up a home mail delivery of their medications was just a game changer, that now they are compliant with their meds and they have less issues with their conditions, as well as helping to coordinate transportation with some of my patients.
Sometimes they weren't going to the doctor because they didn't have a ride. And as sad as that reality is, being able to have them feel comfortable enough to share that with you and then help them, like you said earlier, not in a judgmental way, not in a shame way, but just as a thank you so much for letting me know so that I can do something about it and I can help coordinate transportation to appointments for you.
Another big thing that I remember, a small detail that we would do for some of our members and patients, was after they would get out of the hospital, you know, that's a really vulnerable time for them where they might be on new medications, they now might have to go see a new doctor, follow up after a hospital stay. And life at home,
they haven't been home. Maybe they don't have groceries, things to cook. They might be on a new diet. We were able to help set up meals to be delivered to their home, so that that's just one thing the patient doesn't have to worry about. And kind of circling back to what you said, it makes them feel, the patient feels seen, heard, valued.
That like we are truly here as your care manager to help and not be another just annoying phone call to see if you're doing what you're supposed to be doing. It's more of no, we care. We want to set you up for success. We know these are some barriers and can impact. You know how you feel and how you're able to take care of yourself at home.
So let's try to take some of that burden off of you. That's what we're here for.
Kathryn Anderton
I think it's so important for everyone to talk about social determinants of health, and not as health care providers, just to know of them. We know transportation issues exist, medication, financial, we know all of these things. But what I don't know, everyone is completely caught up on how to investigate, how to understand
curiously, without that shame or judgment. And I know I've seen it before, where a provider asks if a patient is taking their medication and they say no, and then it's a lecture about it's so important that we do this and it's it's almost like the moments already passed for the patient to have the opportunity to communicate, I actually can't afford these.
Maranda Cruce
Yeah. The why behind the action. Agreed.
Kathryn Anderton
So really giving that kind of pause in that space without that judgment but just curiosity. And in a hospital setting it's so often about all right. You have you have hypertension. We need to check and log your blood pressure, low salt diet. But the ability to execute on those is an entirely different mental load.
So to have someone on your side who's helping navigate that. And I think that's where you really need the support. It's day one through seven post-discharge is huge. I think it's so important for care management organizations to realize it's not enough just to assess, but also we need to equip our care managers with the plan to address those.
And that isn't clean. It's not easy. So really finding what's in your community, what you have access to, food banks, DME closets, working with a local dietitian. It's, those can go a long way for your patients.
Maranda Cruce
And kind of a question you asked earlier about what would be, what characteristics would make a successful care manager. I think one of the big things that I'm hearing from you is how important it is for care managers to be curious, that that would be such a huge skill set, because instead of just asking a patient questions, utilizing motivational interviewing, but then being curious to understand why. Why is the patient doing these things?
Why is it their diets not changing? And if it's because there's family recipes that are so important to them that they love these certain foods that they make, you know, being able to empathize with that and then combat some of those things with recommendations that, you know, still align with what's important to them.
Kathryn Anderton
Yeah, absolutely. It's so important.
Dan Godla
Well, that was a great discussion. Thank you Kathryn. There's a lot of good insights in there. And I learned a lot too.
Kathryn Anderton
Oh, I'm so glad. Thank you for having us. It's been great to share our journey and care management with everyone else.
Dan Godla
Well Kathryn, thank you for your time today. Appreciate you being with us.
Kathryn Anderton
Thanks so much for having me here.
Dan Godla
And for those of you watching, that's it for today. Look forward to seeing you on the next podcast.