Patient’s Complex Needs Met Through Integrated Care

Two medical professionals review a patient's chart on a computer.
Rebecca's primary care provider and nurse worked closely together to monitor her care.

Rebecca (name has been changed) has been a patient at Families First since she was a teenager. In her late 20s, she started experiencing alcohol use disorder while also battling an eating disorder. She ended up losing her job, having her car repossessed, and experiencing a number of falls. At one point, she caused a grease fire.

When Rebecca’s conditions worsened, she was brought to the hospital. She weighed 87 pounds, had high blood pressure, was experiencing delusions, and couldn’t walk. She was diagnosed with Wernicke-Korsakoff Syndrome, a brain disorder linked to alcohol use disorder and malnourishment. Rebecca also had gastric bypass surgery at age 17, which complicated her care.

After a two-month hospital stay, Rebecca was discharged. The Families First integrated health care team took over Rebecca’s care.  

“The Families First staff didn’t hesitate to take on the case,” said Rebecca’s mother Linda (name has been changed). “The front desk staff, the nurses, and other staff all went and above and beyond.”

Greater Seacoast Community Health’s patients have the benefit of being cared for by an entire interdisciplinary team of doctors, nurse practitioners, nurses, and social workers, as well as other specialty and support staff. Greater Seacoast includes Families First Health & Support Center in Portsmouth and Goodwin Community Health in Somersworth. Rebecca’s health history was complex and complicated, but was greatly improved due to the experience of the integrated health care team.

As part of Rebecca’s care coordination, her primary care provider, Emily Grattan, made referrals to 18 different specialists. Linda worked with the team to make sure her daughter was able to get appointments with all the specialists. She was talking three times a week to Henri Robitaille, a Patient Service Navigator, who was “always positive and had a great attitude.” Cori Moskal, one of the team’s nurses, also assisted in reaching out to the specialists to make sure Rebecca got the care she needed.

“This is a place you can call home, it’s a home for families, and it’s where you’re a part of the community,” said Linda.

Since her hospital discharge, Rebecca has been participating in a specialized neurological rehabilitation program. She has had monthly appointments at Families First to discuss her progress.  Her foot pain returned and again had difficulty walking. Her provider diagnosed the pain as osteopenia, the loss of bone density, and immediately ordered a test to determine its severity.

“We know my daughter’s case is not an easy one, but the Families First staff treat her with grace and dignity,” said Linda who regularly attends appointments with her daughter.

Now Rebecca is able to walk again, her weight is stable, and she no longer experiences delusions. She will be joining the David Krempels Brain Injury Center in Portsmouth and receiving support services though the state. Linda credits Rebecca’s recovery to the Families First staff.

“This is all due to Emily and the dedicated staff,” she said. “I can’t say enough about them.”

Translate »