Frontline Innovation: Frail Elders Care Management (Health Care Innovations Exchange)
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Frontline Innovation: Frail Elders Care Management (Health Care Innovations Exchange)


My name is Dr. Kyle Allen and
I’m the medical director for Post-Acute and Senior
Services at Summa health system. We worked on really wanting to
focus on older adults who are of low income but also had chronic
disease and functional impairment. Pat’s a kind of prototypic example,
kind of our poster child, if you will. Pat had underlying
medical problems, including diabetes
and hypertension, didn’t have a really good
knowledge and understanding of her health issues, and so she
was having exacerbations of her illness, requiring her to go to
the doctor or go to the hospital. She didn’t have any set goals
and targets for what her blood sugar should be, what
her cholesterol should be. She had a knowledge deficit. She was very overwhelmed by the system, as she said. So that overwhelmingness of
trying to navigate all the pieces and parts that she needed
for her healthcare as well as her social needs
just led to inaction. The patient was seen in their
home after discharge from the hospital and through this
intervention we wanted to try to see if we could activate
the patient for self-care. The care manager really focused
on getting Pat to set goals.: recording her blood sugar so she
can take this to the physicians, understanding what her
hemoglobin A1C needed to be, what she needed to do from a
diet and exercise perspective… I think once Pat started having
more success with her diabetes, you know, then she felt more
empowered and more engaged. I can do this, I’m just not a
passive participant in this, it’s not all up to my
doctor, it’s really up to me. I’m Dr. Kyle Allen, and
I’m a healthcare innovator.

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