Reducing Hospitalizations & Readmissions

January 18, 2016

Chronic care mgmt Maxine Armstrong.jpgAt 86 years old, Maxine Armstrong of Richfield Springs is more active than many people her age and fiercely independent. She walks nearly every day. She drives herself to appointments and she attends as many of the high school’s basketball, baseball and softball games as possible. Armstrong does all of this despite congestive heart failure (CHF), which makes it difficult for her to breathe. One of the reasons Armstrong is able to maintain her independence is thanks to a new chronic care management (CCM) program launched by Bassett Healthcare Network. 

“We see many patients with multiple chronic conditions such as diabetes, CHF, chronic obstructive pulmonary disease and high blood pressure,” says William McCue, FNP-C, Armstrong’s primary care provider at Bassett’s Herkimer health center. “With aggressive management of their conditions, we can improve outcomes and prevent repeat hospitalizations. In Maxine’s case, we’ve been able to do just that.” 

Under the chronic care management program, Bassett clinicians and patients work together to help patients achieve personal health goals and a better quality of life. Specially-trained nurse care managers work closely with patients enrolled in the program to:

  • Answer questions about health, medications or treatments
  • Provide education to the patient and his/her family
  • Connect the patient with other health professionals to prevent gaps in care
  • Help find and use community resources
  • Create a personal care plan with the patient and patient’s provider

The nurse care manager reaches out to patients and families on a monthly basis and is available to discuss any health problems right away and, if necessary, schedule an appointment immediately to prevent an unwanted emergency room visit or hospitalization.

"At my age I need someone who is going to be compassionate and understanding; I’m so appreciative of what they've been able to do for me," says Armstrong. "I had to drag around a 'piece of luggage,’ which was my portable oxygen tank. The care manager, because she knows how active I am, worked very hard to get me tanks that are easier to use. So I have one at home and a smaller portable unit that I leave in my car." 

“The care provided to the CCM patient between office visits is just as important as during doctors’ appointments,” says Donna Anderson, RN, senior director for care management at Bassett Healthcare Network. “Our goal is to help patients remain in their home and out of the hospital as much as possible while achieving the best possible health. The early results are very promising.” 

Bassett patients struggling with a chronic condition such as asthma, diabetes, high blood pressure or a heart condition are encouraged to talk to their primary care provider to see if they might benefit from the individualized approach to their care that the CCM program offers. One Atwell Road, Cooperstown, NY 13326 | (607) 547-3456 

About Bassett Healthcare Network 

Bassett Healthcare Network is an integrated health system that provides care and services to people living in a 5,600 square mile region in upstate New York. The organization includes six corporately affiliated hospitals, over two dozen community-based health centers, 20 school-based health centers, two skilled nursing facilities, and other health partners in related fields. Bassett Medical Center, the foundation of the network, is a 180-bed acute care inpatient teaching hospital located in Cooperstown, NY. To learn more about services available throughout the Bassett Healthcare Network, visit www.bassett.org. Follow Bassett on Facebook and Twitter 

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One Atwell Road Cooperstown, NY 13326

607-547-3456 : 1-800-BASSETT (227-7388)