These days, Gary Henness makes do with home-brew coffee with artificial sweetener – and whipped cream, on occasion. It all started when the type 2 diabetic shared his coffee of choice with Erin Bartek, a registered nurse and Certified Diabetes Educator who is part of The Corvallis Clinic Care Coordination Department.
“One of my first questions to him was, ‘What’s a breve?’,” Bartek said.
Specifically, it’s a caramel breve. “It’s a drink that has half and half and seven pumps of caramel with whipped cream,” Henness said. Bartek helped Henness realize that his treat was likely contributing to his weight gain and elevated blood sugars. “Now I try to stay away from all that sweet stuff,” he said.
Bartek’s gentle guidance and persistence in getting to know her patients is part of the coordinated, continuity of care Henness has received as a Clinic patient since 1988.
Comprehensive Primary Care Initiative: All About Coordination
The Corvallis Clinic developed its Care Coordination Department in 2012 after it was one of 481 primary care practices in the country and one of 67 in Oregon chosen to participate in the Comprehensive Primary Care Initiative (CPCI), a federal program aimed at strengthening primary care through better patient-care coordination. Practices were selected through a competitive process based partly on their recognition of advanced primary care delivery by accreditation bodies, use of health information technology, and participation in practice transformation and improvement activities.
“We are essentially case managers for The Clinic’s internal medicine and family medicine primary careproviders,” Bartek said, “We help patients problem solve, improve their quality of life, and ensure good communication within their health care team.” Care Coordination staff check up on patients who have been released from the hospital, first making sure they are doing okay, and then they review their medications and ensure they are receiving appropriate follow-up care.
“We make sure all the information is available from the hospital when our patients go to their follow-up appointment,” said Lindsay Rickli, a registered nurse in Care Coordination who is scheduled to take the Certified Diabetes Educator test in December. “So everyone is on the same page.”
Care Coordination also helps patients connect to resources in the community, such as senior and disability services, prescription assistance programs, home health, hospice, meals on wheels, mental health resources, and respite care. “We are essentially the discharge planners in the clinic,” Bartek said.
Registered nurses on the team are also available for patient education. “Our focus is attempting to prevent problems,” Bartek said. “For example, many older people are at risk for a fall. So, we help patients and families utilize resources in the community and make changes within their home to help prevent falls from occurring in the first place.” And their help extends beyond older adults.
“We get notification of emergency room visits and hospital admissions for all ages,” Rickli said. “We follow up on even our youngest of patients who see our family medicine providers, helping to coordinate care for infants to teens and their families.”
Continuity of Care: Multispecialties
Henness, a former HP employee who now works part time as a technician for a contractor at the Corvallis site, was diagnosed with type 2 diabetes at age 36. He later was diagnosed with leiomyosarcoma (lie-o-myo- sarcoma), a cancer of the smooth muscle.
“The prognosis was listed as ‘very grim’,” Henness said. Dr. Peter Hudson, a Clinic surgeon, removed the original tumor in his upper leg. The disease eventually led to the amputation of his right leg below the knee.
“I’ve had so many different procedures done at The Clinic, it’s like a second home at times,” the 62-year-old Albany resident said. His list of Clinic physicians consists of his primary care physician, internist Brian Curtis, along with podiatrist John Murphy, endocrinologist Lindsay Bromley, urologist Michael Brant, neurologist Shelly Svoboda, gastroenterologist Sooyun Chun, and orthopedic surgeon Richard Stanley.
“I’ve always felt welcomed here,” Henness said. “I feel like I’ve gotten good treatment. The doctors are caring individuals, looking out for the best for you.” Henness has had surgery with Dr. Stanley for a torn rotator cuff and a detached bicep and to remove part of his collarbone. “I love Stanley,” Henness said. “He’s a great doctor.”
Diabetes Focus
As RNs who started in The Clinic’s Endocrinology Department, Bartek and Rickli spend lots of time working with people with diabetes, such as Henness. They teach patients how to measure their glucose level with a glucose meter, how to use and adjust insulin, how to wade healthfully through a grocery store and kitchen, and how to problem solve and reduce stress, along with guidance on changes to improve their health and quality of life.
Bartek said it is all just part of establishing a relationship with patients and getting to know their priorities, what Henness said he has experienced with other Clinic nurses.
“You feel like they really know you,” Henness said, “like you are their friend. They are more than just a person doing a job.”
Like any “friends,” they look out for you.
“I think we should work on getting you back down to 200 pounds,” Bartek said to the 225-pound, 5-foot eight- inch Henness during a recent “healthy” lunch. “That’s fine,” he responded cheerfully.
“Erin is always bugging me,” Henness adds with a laugh: “‘What’re your blood sugars?! What’re your blood sugars?!’ She’s really good at checking up on you.”
And at putting the kibosh on the caramel breves.
