Spotlight on Success: Care Coordination Through SQCN

November 2014

Mr. Scott, like so many of us, knows what he needs to do to live a healthier life. As a diabetic patient, things like managing blood sugar, improving his diet and making sure he exercises regularly will help him keep his disease in check and allow him to maintain a higher quality of life. However, Scott admits that knowing the right things to do and actually doing them are not always one and the same.
Then Mr. Scott met Jossett Smith, a Care Manager with the Sentara Quality Care Network. He knew he had diabetes and he knew many of the steps he could be taking to help in the management of his disease, but he was – for whatever reason – not doing everything he could.

Smith recalls her first meeting with Scott. His A1c was 8.5, he had an ulcer on his ankle that had been there about one year and he rarely checked his blood sugar. After spending time with Scott, Smith helped him with some specific strategies to help him bring his diabetes under control.

"It dawned on me that I needed to buckle down and follow the guidelines," says Scott.

After meeting with Smith, Scott says they mapped out several steps. First was an inventory of medications and how they were being managed. Next came an honest look at nutrition and diet choices and Smith was able to provide specific information to help Scott improve his eating habits. And since Scott was not checking his blood sugar enough each day, they made that a priority as well.
Smith pointed out that Scott was on a sliding scale for insulin, which meant that his dosage was dependent on his blood sugar level. Scott had been using guess work to figure his insulin dosages, so Smith encouraged him to take his blood sugar before administering the insulin so that he would know how much insulin he needed.

This new resource for Scott, coupled with his positive attitude, really helped him make changes for the better. "I'm 65 years young and I know I can't change the past, but I can focus on what needs to be done today and going forward," Scott added.

When it came to diet, Smith learned that Scott did not eat breakfast and, instead, ate heavily later in the day. She also learned from talking with Smith that he enjoyed bread, but was under the impression that those diet choices were all or nothing. Smith educated him about the importance of breakfast and not skipping meals. She also explained that no food has to be off limits as long as he plans his meals carefully and pays attention to caloric intake and portion control.
Scott said that feeling accountable to someone really helped keep him on the right track. He talked with Smith regularly and they met in person about once a month. He now uses his blood sugar log more effectively, maintains better eating habits and continues to exercise three times per week which has all led to better health.

Smith was thrilled when Scott called to share news from a recent doctor visit that his A1c was 6.7 and his ulcer was finally healed.