 Provided by Clinician 1
In my monthly quest to keep medical home data up-to-date, I run our medical home “formulas” for diabetes, colo-rectal screening, and breast cancer screening twice per month. This allows me to review patients’ charts for missing data, which includes their HgbA1c, LDL levels, etc.
Over the past nine months, my diabetes registry has had the same names popping up with missing lab data. For each patient, I audit the chart to make sure that the “missing” data wasn’t merely entered incorrectly, and to make sure that the person was given a lab slip at his or her last visit. As you might imagine, this chart review takes time and makes for tedious work.
One such individual has made my personal “MIA” list every single month. “Mr. A.,” a 61 y.o. male, obese, with HTN, had his last labs in April, 2010—his first labs as a new patient in our practice. At that time, his A1C was 10.6, and he was NOT on any DM meds. He was counseled about his disease and told that he needed medication, but somehow he apparently stated that he was not ready and left. Several follow-up visits were canceled, he was hospitalized out-of-state, and then we did not see him for another YEAR.
Every subsequent visit was a “sick” visit...he hadn’t been seen often, but each time, he had left with a new lab slip and a request to get blood work done. No medication was prescribed for his DM, as we didn’t have any recent data on renal or liver function.
Up to this past week, I admit, the extent of my knowledge of him was my bi-weekly chart audits in pursuit of his lab results, as he sees my collaborating physician. All I knew is that there were no labs on the chart, and we had given him slips to get them done. Quite honestly, I didn’t even look at the EMR screen to realize that he was not on medication. When you track hundreds of DM patients...well, the seemingly “minor” details get glossed over.
This past week, he came in to see me for the first time, for a pre-op visit for cataract surgery. As I saw his name on my schedule, I figured that I would personally have the chance to discuss getting his labs.
Then...I reviewed his entire chart...fortunately, BEFORE his visit.
I realized the extent of the issue...A1C of 10.6—17 months ago. No DM meds or statin. He was on an ACE-I and ASA for HTN, but that was it. What I would discover was that the “teaching moment” was really MINE when I walked into the room.
After my introduction, I asked him about his upcoming cataract surgery. It turns out that he failed the vision screening twice at his pre-employment physical to be a deputy sheriff. Long-story-short, he ended up needing cataract surgery, so he would have bilateral cataract removal and lens implants done within the next month. All he wanted to do, he said, was get this DONE so he could get back to deputy work. I listened to the passion in his voice, as he detailed how much he longed to get back on the job. I realized how frustrated he was to have this “inconvenience” of surgery hold things up. Then I realized the greater picture...or so I thought.
I asked him why he had not gotten the labs done, after so many attempts at doing so. We had even given him the site of a lower-cost lab site. “They wouldn’t take my lab slip at that site,” was his first response. I was confused...I reviewed the chart, noting to him that I’ve never had a problem with them before, and if so, I wished that he had called us to straighten it out.
Then...the truth came out. His insurance did not cover blood tests, and he couldn’t afford the $24 for the A1C...or the $16 for the CMP. The combined price for a CMP, CBC, and lipid profile was $49...and he could not pay for it.
I sat on my stool, stunned for a moment. I live in suburban northeast PA, and we have a lot of blue-collar workers and people without insurance, but this was a surprise to me.
I explained my concerns about his not having labs in so long...that he had already had uncontrolled DM for quite some time, and that, my bigger concerns were the risks he had with not treating it appropriately. It wasn’t, I said, merely a matter of fixing his cataracts. What about the risks of delayed healing...diabetic neuropathy...kidney damage, heart disease, stroke, etc. I wanted to help him get BACK to this job, and do it safely. What if his future employer found out he had uncontrolled diabetes?
“My wife handles all that...I’ll have to ask her if I can get them done,” was his response.
I teared up, listening to his stoic response. His arms were crossed over his large abdomen, firmly staring me down. Darn it, if I had a dime for every time I’ve heard this in the past few years...and if only I was independently wealthy to pay for each-and-every one of them. Memories of my grandmother’s uncontrolled DM leading to end-stage CHF, renal failure, CVA, and hemiparesis flooded over me. I had to swallow the lump in my throat.
Very gently, I told him that I was genuinely concerned about his health. “I will help you,” I said, “but I need to see where things are right now, so that I can safely prescribe medication for you. Please...let’s just get the absolute basic lab work, so that I can do that.”
His gaze softened for a few seconds. Then he repeated the same thing...he would check with his wife if they could afford to have him get the blood work. I hoped that my words would help to sway him.
This Friday, my staff made their “reminder” calls for upcoming patient visits. Mr. A. was on the list. My medical assistant had noted my reminder to check if his labs were done; our usual policy is to reschedule the DM visit if they were not done prior to the visit. She reviewed his chart...and found no lab results. I heard her speaking to the MA student, telling her the policy, and that we would reschedule his visit. I stopped her from doing that.
“We need to make an exception for him...look at the alert note in the chart,” I said.
I had put a statement--in bold font--on his alert sheet after our visit...”please be careful about ordering labs—no insurance for routine blood work.” Sometimes, medical home audits and data be damned, we need to remember the patient’s situation as well. We’ll use this next visit to try to drill the point home again.
 Kim Spering is a family nurse practitioner who currently works at Brndjar Medical Associates, P.C., a family practice in Emmaus, PA. Her past experience includes the fields of medical/surgical ICU, open heart/trauma ICU, labor and delivery, nursing education, nursing supervision, and as a nurse practitioner in both family practice and OB/GYN settings. She currently serves as a NP preceptor for her graduate school alma mater, DeSales University, as well as for local baccalaureate programs. She is passionate about patient education and helping patients understand that they are ultimately responsible for their own health. She also firmly believes that the public needs to be educated on the value of NPs and PAs in meeting the health care needs of the next decade and beyond. In her free time, Kim enjoys family vacations with her optometrist husband, Mark, and her two sons, Matthew and Connor.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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