Care Management Team Partners with High Performing Nephrologists in MDX Network

Meet Mr. Robert* Age: 71

Mr. Robert, a 71-year-old male, was a smoker for 40 years and frequently drank before he managed to quit both ten years ago. This history, paired with lifelong obesity, led to health issues in 2019, when he had three ER admissions due to chronic heart failure and shortness of breath. During one of the ambulance rides to ER, he experienced multiple cardiac arrests. Simultaneously, he experienced a rapid decline in Glomerular filtration rate (GFR), indicating a worsening kidney function. Mr. Robert has been diagnosed with hypertension, hypersensitivity lung disease, coronary artery disease, peripheral artery disease, atrial fibrillation, and chronic heart failure.

In 2020, the patient agreed to participate in the MDX Hawai’i care management program and began to log his daily weight and blood pressure. Unfortunately, his GFR continued to decline, and he was referred to a nephrologist. Despite multiple attempts by the care management team to schedule appointments, the patient refused to see the nephrologist.  But perseverance paid off.

Bobbie Becker, care manager at MDX Hawai’i, continued to work with Mr. Robert and convinced him to see a nephrologist. He was also referred to a cardiologist. Bobbie continued to follow up with the patient to ensure that the patient complied with the treatment prescribed by his physicians.

Over the past months, Mr. Robert has made efforts to improve his health and lifestyle. He is staying active with a daily walk, improving from 3,000 steps every morning in September to 6,000-7,000 in December. Mr. Robert has made significant changes to this diet with a DASH diet plan frequently recommended for patients with kidney disease. He also has established care and sees his nephrologist and cardiologist regularly. “I am feeling better than I have for years,” said Mr. Robert. “I had the scare of my life when I had a heart attack on my way to the hospital.  Now, I am only two pounds away from my goal weight. I was lucky to have met Bobbie and find a smart nephrologist. Both practically saved my life.”  Mr. Robert continues, “I will continue my healthy habits for the rest of my life. They are not that difficult.”

*To protect the privacy of the patient, an alias was used.