Chronic Diabetic Care Management

Participating Organizations: Brightree, Cerner, MatrixCare, Netsmart, STCHealth

Fatima presents to the ED via ambulance after confusion with a headache, a heart rate of 126 beats/min, and high glucose readings. She has a history of repeat ED visits for her type 2 diabetes. Fatima was recently in a motor vehicle accident and is wheelchair bound due to a right femur fracture - open reduction and internal fixation. Her surgical incision site looks red and is hot to touch. Fatima stated that she had not felt well for several days due to fever, nausea, and vomiting. She tests negative for COVID-19 and flu. The ED queries the state immunization registry and sees that she does not have her flu shot or second Covid-19 vaccination. Fatima is a professor without family members to help her at home and has difficulty managing her diabetes and foot care. The ED physician sees Fatima is struggling to adjust to her new lifestyle due to her immobility and isolation from the COVID-19 pandemic. She is concerned that the patient will return to the ED without proactive care and orders home treatment. Follow Fatima on her transitions of care journey that incorporates various parts of the healthcare ecosystem using Direct Secure Messaging, HL7® FHIR®, and 360X.