By Thomas Vincz, Public Relations Manager

The Diabetes educator coordinating Marty Perzan’s care said her patient felt “shocked” by his diagnosis. Marty himself put it another way: “It scared the living daylights out of me.”

A 65-year-old Horizon member from Highland Park, NJ, Marty tested his blood periodically to stay on top of his blood sugar count. He tried to watch his diet and stay active knowing full well that he, like his late father, was at risk of developing Type 2 Diabetes.

Marty’s sugar levels fluctuated on the fringes of acceptable over the course of several years of occasional screening. But after a blood test showed highly elevated A1C and blood glucose counts, he conceded, “I lost control.”

While he may have “lost” control, he said he was “found” not long afterward by “Nurse Jackie.” That would be Jacquelyn Plick, RN, BSN, MA, APN, CDE. Jackie is an advanced practice nurse and a Diabetes educator for the RWJBarnabas Health Accountable Care Organization (ACO). RWJBarnabas Health is an OMNIA Alliance member and partners with Horizon to improve patient care while enhancing the patient experience for the Horizon member and controlling health care costs.

An ACO is an organization of practices that has a laser beam focus on helping Horizon patients achieve and maintain their optimum health. ACO care is coordinated among all doctors and specialists treating a patient, and is tailored both for those who are well (to keep them that way) and for those with, or at risk of having, a chronic condition (to help them manage the disease and live life to its fullest).

Marty brought his elevated sugar counts to his primary care physician, who made the diagnosis and prescribed Diabetes medications. “Two weeks later, I got a call from Nurse Jackie, and then she came to my home and we discussed everything, from when and what I was eating for lunch and breakfast to what medications I was taking,” he said.

“I sat in (Marty’s) kitchen with him and took a list of what was around me. I asked questions about the food he was eating, where he keeps his supplies and medicines and how that is coordinated,” Jackie said. “With our high-touch model, we feel we can better understand barriers to a patient’s meeting his or her health care goals. We see them in their home. We see them in the (primary care doctor’s) office, and we talk to them over the phone so we can really understand the total patient.”

RWJBarnabas Health is able to identify at-risk patients like Marty Perzan and deploys educators and coordinators like Nurse Jackie to them because of the claim information the ACO and other OMNIA Alliance providers receive in collaboration with Horizon. This information helps Horizon and its providers to manage and improve the health and quality of life of their at-risk patient populations.

“She went through how diet and exercise can lessen the effects of Diabetes. She was also very insistent that I get my feet checked and eyes checked -- things that a doctor may or may not tell you in the office. When you go to the doctor’s office, you may only get a few minutes and lots of times, you can’t really think of the questions to ask. You have to really sit and talk about it – what I ate, how I slept and other health issues. They’re all interrelated, and that made it real. With Nurse Jackie, we discussed everything.”

“Providers are good educators but don’t have the time and are under pressure to see patients quickly,” Jackie said. “For educators and care coordinators, what we do is help people understand what’s going on with their chronic illness and to break it down and simplify it as much as we can, piece by piece, so they can find that balance with their everyday life with wellness.”

After their initial meeting, Marty began working on his goals established with Jackie. Four weeks after that first visit, Marty shared some positive news with his Diabetes educator in a follow-up home visit. “My glucose level, which was about 300, fell to just over 100 – much more manageable. We caught the whole thing in time. Quick intervention was key,” he said.

Today, Marty’s sugar levels remain in the safe range and he says he feels more empowered by the self-management skills he’s received from Nurse Jackie to keep healthy. What were once long sessions in his home are now what he calls “check-in conversations” over the phone with his care coordinator.

“I hate the fact that I have (Diabetes),” Marty continued. “I am resigned to the fact that with diet exercise and medication, I can keep it under control. Years ago we were with another insurance company and we would get a phone call from a nurse from time to time. With Jackie, care was more personalized and that’s a better result.”