Evo Terra (Host): Welcome to another episode of Arbor Health and Life Podcast, where we engage with trusted medical experts from Arbor Health. I'm Evo Terra and I'm here with Kelli Cotton, a Chronic Care Management Nurse with Arbor Health. Thanks for joining me, Kelli.

Kelli Cotton, MSN, RN: Thank you for having me.

Host: I like to start these conversations at the beginning. What is chronic care management?

Kelli Cotton, MSN, RN: Chronic Care Management is a Medicare backed program. It is for patients with two or more chronic conditions. And with that, you would have a nurse, myself, that you would could call and I would help you schedule doctor's appointments or labs or answer questions about your chronic condition or medications. 

So really, I like to think of it kind of as like a back line or a direct nurse line, for your health through your primary care doc.

Host: That's fantastic. Tell me a little bit about Arbor Health's approach to chronic care management and specifically who's on the team? You, you mentioned the primary care physician, you as a nurse, but tell me more about what it happened, what happens at Arbor Health.

Kelli Cotton, MSN, RN: So Arbor Health, has a fantastic team, and they can touch on all different chronic conditions. They have specialty providers as well as a licensed clinical social worker, psychiatric nurse practitioner, as well as your primary care doctors, your MAs, clinic managers and nurses as such that are there in the clinic and do hands-on.

I work really closely with all of them, depending on what your conditions are and what your needs are for the future and or currently. And then yeah, we just work together as a team to make sure that all of your healthcare needs are met and nothing falls through the cracks.

I'm sure the patients really appreciate that. Speaking of patients, what's a visit like for a patient who's part of the CCM team?

As a CCM nurse, I reach out to every patient at least once a month. So you would have my direct phone number, and you could call me whenever you need anything. You have a question, concern, anything like that. You could call me directly. I like to say I have a little backline with their provider if they have a question for their provider, so I can get to them pretty quickly with an answer.

Kelli Cotton, MSN, RN: And then if I don't hear from you, then I pick up the phone and give you a call. So usually I like to say I, I touch every patient at least once a month. Whether that be looking through your chart and making sure that all the doctor's orders from your last visit have been completed, any specialty doctor you have, like a cardiologist or endocrinologist; those notes from your last visit are in the chart for your primary care doctor. So I just kind of go through the chart, make sure everything's in order, and then reach out. Say, Hey, how's everything going? If you don't need anything, that's okay. And if you do have any needs or concerns, then we can address those at the time.

Host: When a patient comes into Arbor Health, and is meeting with their endocrinologist, for example, are you there with them or does the chart that you've assembled and put together the documents, give that physician everything they need to help that patient?

Kelli Cotton, MSN, RN: I'm not in the clinic, directly with the patient, but I make sure that all of the information that the doctor needs for that visit is there. So I like to do if I can a pre-visit call. So I would call you a day or two before your visit, say, hey, is there anything specific that you want to discuss while you're meeting with your doctor and then send the provider a email or communication message and say, these are the patient's concerns. It looks like they haven't had labs done in six months or a year. Do you wanna consider ordering any labs? And so we can kind of work through things that way.

Host: Is every patient at Arbor Health eligible for their chronic care management program?

Kelli Cotton, MSN, RN: Not every patient. Like I said, it's a Medicare backed program, so it's for Medicare and Medicaid patients that have at least two chronic conditions. So that can be diabetes, hypertension, hypothyroid, there's a lot of chronic conditions, so unfortunately a lot of people qualify especially 65 and older. But yeah, so the chances that they qualify for the program are pretty great.

Host: Yeah, I would think so. Tell me a little bit about the benefits to the patients and maybe touch on some of the outcomes you've seen for patients that are part of the CCM Management program.

Kelli Cotton, MSN, RN: Benefits are, I think that one of the greatest benefits is you get a direct line to a nurse. And because a lot of times these days, you'll reach out to the nurse in the clinic, they're busy rooming patients or helping with physicians, you know, doing their specific jobs. And so it might take them a little bit longer to get back to you.

So having a direct line to a nurse who that is her job, to take your phone calls, and return phone calls; I think that's one of the biggest benefits. I work with patients that their diabetes, their A1C is elevated and it scares them, rightfully so.

And so, we work together on lifestyle changes, diet, exercise, finding out causes that, why their A1C or their blood sugars have been running so high. So we work as a team. They have an individualized nursing care plan for them. And when we talk every month or every couple weeks, we touch base on that care plan and say, Hey, you were talking about adding more vegetables to your diet, or adding more fruits, or whatever the case may be, and um, or walking around the block every day. How's that going? And so just kind of like a support system for them as well.

Host: Yeah, I can definitely see the benefit of having a nurse like you in someone's corner to make sure all of those things are working. That nursing hotline that you talked about, the nurse care lines, sounds fantastic and this whole program sounds quite beneficial. So I guess if you had to sum it up, what's the biggest outcome that patients love?

Kelli Cotton, MSN, RN: I think patients love that they have somebody to talk to about their chronic conditions. They're not alone. When I was working in the hospitals, I always went into a patient's room when the provider was there to hear what the provider was telling the patient. And then when the doctor would leave, I would kind of tell the patient again, in layman's terms, what the doctor just said. Because a lot of times you don't understand. And, if you're by yourself, you don't really hear what they say. So, I think knowing that you're not alone in your chronic conditions, you're not alone with questions that you have.

There's no stupid question. There's no dumb question. I get all kinds, you know, very complex issues as well as just can I go and do this while I'm on a blood thinner type questions? And so, but I think it gives people peace of mind that they've talked to a health professional and they have a answer. And if I don't know the answer, I find out the answer for them.

Host: That is really fantastic because look all of our physicians and our nurses are incredibly busy people. They're doing lots of things out there, but knowing that there is a nurse in your corner as a patient to really pick up the phone and not make you wait 72 hours has to be an amazing feeling for everyone involved.

Kelli Cotton, MSN, RN: Yeah.

Host: That's great news. Anything else you'd like to share about the program we didn't cover already?

Kelli Cotton, MSN, RN: No, I just think it's important that we talk monthly and, as the CCM nurse we're available for any questions, any concerns. And, you know, that's my joy, to help people through their journey, whatever that might be.

Host: Fantastic. Thank you very much for joining me today, Kelli.

Kelli Cotton, MSN, RN: Thank you so much. I appreciate it.

Host: You can find out more about the Arbor Health Chronic Care Management program at myarborhealth.org/chroniccare, or talk to your primary care provider for a referral. 

And this has been another episode of Arbor Health and Life. Thanks for watching.