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A team approach to targeting congestive heart failure



Ted Hanberg at home with his daughter

May 3, 2011 - A coordinated approach to health care is helping patients such as Ted Hanberg manage several chronic illnesses at once without landing in the hospital every few weeks.

Hanberg, 83, has several chronic illnesses including diabetes, kidney disease and congestive heart failure. He has had five heart attacks during the past 18 years. He takes 13 prescribed drugs a day, including three blood thinners. Between early December and mid-March, he was hospitalized four times, each for six days or more.

Hanberg and his wife Mary live in their own home in Happy Valley. Their daughter and her husband live with them and help with their care. Also important is Mr. Hanberg's new health team, which uses the coordinated care model to help patients manage chronic conditions. With a focus on managing high-maintenance illnesses such as congestive heart failure, this approach helps keep patients healthier while at the same time avoiding higher-cost hospital admissions. The team includes doctors, nurses and medical assistants. A nurse acts as case manager, keeping Hanberg's primary care doctor in the loop.

"They watch over me," he says of his coordinated care team. He calls in once a week to report his blood pressure, weight and any health changes. In an emergency, he can page the team. He also sees his primary care doctor weekly.

"They all talk to each other," says Hanberg, a retired radio engineer. "I like that."

More importantly, since mid-March, Hanberg hasn't been back in the hospital.

"That is their goal - keep me out of the hospital," he says.

It's his goal too. Staying out of the hospital keeps costs down, but it also means Hanberg is feeling better and keeping his chronic illnesses under control. "I feel fine most of the time," he says.