Success Stories

Mr. M. and FIDA through Fidelis

Perhaps one of the best examples of what the FIDA (Fully Integrated Duals Advantage) program means to a member is illustrated with the cooperation of the permanent team and care transition team, which are both part of the FIDA Care Management Team.

Mr. M enrolled in Fidelis FIDA on January 1, 2016. He is a 62 year-old male with a past medical history of Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF) with ischemic cardiomyopathy and apical thrombus, coronary artery disease, status post stents, hypertension, hyperlipidemia, diabetes mellitus, chronic kidney disease, stage five chronic kidney disease.

It was brought to the attention of Fidelis that Mr. M was admitted as an inpatient due to COPD exacerbation and blood-tinged sputum to a Coumadin clinic on January 4, 2016. Coumadin Clinics monitor and provide medication that helps prevent blood clots. Mr. M was discharged home on January 8, 2016 and his Care Team followed up by scheduling an appointment with his Primary Care Provider (PCP) and priority assessment at home. The field nurse who performed the assessment reported to his Care Manager (CM) on January 12, 2016 that Mr. M refused to take any medications. The nurse then followed up with his PCP and the Coumadin clinic.

The permanent team and care transition team had an urgent huddle and identified the barrier of care and the action plan. They planned to educate Mr. M on his medical conditions, how blood clots form, eating and living healthier, monitoring his blood pressure, and following up with his CM and the Coumadin clinic for routine check-ups. The care team also identified Mr. M´s health goals with him and then assessed and assisted in reaching these goals, which included increasing activity, obtaining assistance from area resources to get a psychology appointment, and potentially changing his pharmacy and prescription plan.

Some nursing services that were covered as Mr. M´s plan of care included:

  1. Weekly calls for post-hospital follow-up: changing short-term and long-term goals, disease education and management, and medication and medical appointment compliance
  2. Referrals for a physical therapist and medical social workers
  3. Coordination of medical appointments
  4. Transportation logistics
  5. Coordination of home lab for Prothrombin Time blood testing
  6. Post-hospitalization Uniform Assessment System assessment
  7. Post-hospitalization Interdisciplinary Team (IDT) meetings: medical diagnosis, medication reconciliation with PCP, discussion and alterations of care plan to be an appropriate level of care

After receiving a multitude of services and a helpful telephonic consultation, education, and IDT meetings with the PCP, Mr. M not only reported feeling better, but also gained a much better understanding of the disease processes and why medical treatment is so important for him. Therefore, his compliance with the plan of treatment and goals improved. Happily, his COPD, CHF, Hypertension, Coumadin clinic management are currently "At Goal."