Norma Bonney

Sometimes and In-home Visit Makes All the Difference

Norma Bonney needed some intense intervention. A pattern was starting that had her provider and nurse care coordinator at EMMC’s Husson Internal Medicine concerned. Six years ago, Norma was diagnosed with diabetes and COPD (congestive obstructive pulmonary disease). Up until recently, she was managing them well, and then her primary care team noticed something wasn’t right. In the course of six months, Norma had gone to the emergency department six times and twice was hospitalized. That’s when Eastern Maine HomeCare’s Community Care Team was asked to step in and see what was happening in the home providing a 360 view of Norma’s life.

It was quickly determined that Norma was running into trouble because she was forgetting to take her medicine causing her blood sugars to spike into the 600s. She was tripping over her oxygen cord and was overall not very safe in her home. “I was able to go to Norma’s house and sit with her and find out what was going on,” shares Alison Ashley, LCSW. After medication reconciliation was done, it was evident that Norma’s living arrangements weren’t ideal and neither was hygiene or nutrition needs. “Not to be dramatic, but I felt like if something didn’t change, Norma would die.”

With the help of the Community Care Team, Norma moved into an assisted living facility. She also began including a friend in the conversation to help her remember appointments and to keep her medications straight. Additionally, a nutritionist is teaching Norma about nutrition and diet to help with her diabetes, and Alison is helping her get dentures so she can eat carrots and other fruits and vegetables.

“It’s really about building a support system with services provided in our community along with the trusted people in their lives – it’s making a world of difference for these people,” Says Alison. Community care team members are constantly keeping the patients primary care team in the loop in order for coordination of care to continue at the highest level.

It’s now been more than six months and Norma hasn’t been to the emergency room once. Also, with the help of the Community Care Team and electronic medical records, Norma’s primary care provider and nurse care coordinator know who to call if they have concerns.