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In Home Care Keeps Lou Healthy and Strong

by UPMC Susquehanna

Louis Robbins of Williamsport likes to keep busy, so staying healthy is key to keeping him happy. 

“I may be 88, but I like to be active and on my feet,” said Louis. My nurse in the Ambulatory Nurse Care Management Program in the Care Transitions department helps me do just that.” 

In 2016, Louis was hospitalized at UPMC Williamsport for some health issues. At the time, UPMC was starting a new program called Ambulatory Nurse Care Management. The community-based care coordination program was aimed at improving the health of patients that have chronic conditions such as heart failure, chronic obstructive pulmonary disease (COPD), and diabetes.

“I had a heart attack in 2001 and have a pacemaker,” said Louis. “The nurse explained that they wanted to come to my house and check on me to make sure I was taking care of myself.” 

Staying Out of the Emergency Department 

The Ambulatory Nurse Care Manager was designed to establish long term therapeutic relationships with participants and their families to provide comprehensive, patient centered preventative care management services that help enhance the participants abilities to self-manage their chronic conditions, promote appropriate utilization of health services, and to develop new skills to better manage their chronic conditions in their homes to improve the participant’s overall health satisfaction and quality of life. 

The ultimate goal is to keep the patient healthy so, they don’t have to visit the emergency department as often and can avoid unnecessary hospital stays. 

Courtney Newlen, BSN, Louis’ nurse, visits his house every three to four weeks providing ongoing monitoring and assessments, by taking his blood pressure, checking his weight, reviewing his medications and performing a medication reconciliation, and check-in on how he has been feeling. If Louis has any health concerns, he can talk to Courtney about what to do.  

“I have had the same nurse for three years,” says Louis. “Courtney is great — but tough. She keeps me in line, and if she thinks something doesn’t look good, she follows up with my doctor. I try to do everything she asks me to do.” 

Healthy and Happy 

“For the last three years, I haven’t had any major health issues, and at 88 that is pretty remarkable,” said Louis. 

Louis and his wife, Jean, volunteer at UPMC Williamsport three days a week. He feels it is important to give back to the people helping in the community. 

Improving Health for All 

Since the program started in 2016, UPMC has seen significant improvement in health outcomes. In 2018, the patients enrolled in the Care Transitions program had a 29.5% reduction in emergency room visits, and hospitalizations were down nearly 25.5%. 

“I don’t think enough people know about this program,” said Louis. “Courtney is like a supportive family member working to keep me healthy.” 

Are you or a loved in need of assistance navigating and coordinating your health care? Talk to your primary care provider for a referral to the Ambulatory Nurse Care Management team at UPMC.