Judy is a 70-year-old female who was identified for the Spiras program because she had a history of emergency room visits and multiple chronic conditions, including high blood pressure, high cholesterol, and COPD.

Assessing the patient in the home

When Spiras first met Judy in her home, her breathing was heavy and labored. The Spiras Care nurse noticed that she had severe edema in her lower extremities. After the assessment, the Spiras clinical team was concerned the patient was experiencing an exacerbation due to congestive heart failure (CHF).

Judy told Spiras that she had a primary care physician who was following her care but had never talked to her about CHF. She also said that, though her breathing was labored, she had no intention of calling her primary care physician.

Communicating with PCP and specialist

A Spiras Care nurse practitioner talked to Judy’s primary care physician about her concerns and a potential CHF diagnosis. Judy was immediately put on a diuretic regimen. The clinician discussed the importance of a low sodium diet and monitoring her weight and fluid retention. Spiras Health also coordinated a visit with a local cardiologist who confirmed the CHF diagnosis.

When Spiras returned to Judy’s home for a follow-up visit, she had lost 13 pounds; her breathing was normal; and she felt great. Spiras made sure she had prescriptions for both her heart and lung conditions and the importance of taking both, even on days when she felt fine.

Monitoring the patient’s health and treatment plan

Judy was also given an emergency kit which included some rescue medications. She was instructed to call her personal Spiras clinical team at any time should she begin to have trouble breathing or if she begin to gain weight and retain fluids. Follow-up visits were scheduled over the next months to monitor her health and make sure her treatment plan was working.