You Are Never Too Old to Achieve Your Goals
By: Katherine Czarnowski, PharmaD, BCACP and Pearlene Martell, LCSW, LICSW
SoNE HEALTH team members take pride in practicing the organization’s values every day. Our values reflect our SoNE HEALTH mission to optimize patient care in collaboration with our providers and other stakeholders. The case shared by our Clinical Pharmacist and Behavioral Health Specialist exemplifies the value of inclusivity in honoring each person’s individual qualities of whom we work with and serve within our Population Health Management team. The following patient case also shows the benefits of a multidisciplinary approach to comprehensively meeting patient needs.
The SoNE HEALTH clinical pharmacists optimize medication regimens, identify potential barriers to adherence, and educate patients on managing their diabetes effectively. Our Clinical Pharmacist, Katherine Czarnowski, called a 72-year-old male patient with a history of poorly controlled diabetes and a Hemoglobin A1c (HbA1c) level of 8.9%. The HbA1c reflects the patient’s average blood sugar level over the past three months. One of the patient’s goals with improving his diabetes was to reduce his A1c to less than 7%.
In addition to experiencing high blood sugar, the patient also had low blood sugar. The patient’s diabetes medication regimen included Lantus insulin and Trulicity. Katherine reviewed the patient case with the patient’s primary care physician with the aim of lowering the patient’s Lantus insulin dose and increase his Trulicity dose to lower the patient’s A1c level while minimizing the risk for low blood sugar. At the patient’s next blood draw, the patient’s A1c level improved to 6.7% but he continued to have occasional low blood sugar during the day whenever he skipped a meal. Through conversation, it was discovered that the patient was feeling depressed because of difficulties in a personal relationship. The patient mentioned that his depression was affecting his appetite where he was no longer eating regular meals as he did in the past. Katherine gained the patient’s consent for a referral to the SoNE HEALTH behavioral health specialist.
Our Behavioral Health Specialist, Pearlene Martell, reviewed the patient’s case noting the 72-year-old male patient immigrated to the U.S. from Africa several years ago. During the telephonic behavioral health assessment with the patient, Pearlene surmised the patient experiencing increased stress related to his interpersonal relationships, work, and medical conditions. The patient expressed feeling very overwhelmed with the stressors negatively affecting his mood. The Social Influencer of Health screening helped to identify that the patient had an inadequate support system and felt isolated. A PHQ-9 assessment was conducted resulting as positive. Although Pearlene recommended a referral to a Behavioral Health provider in the community, the patient declined at that time.
Pearlene assessed the patient’s behavioral health needs as well as provided behavioral health resources and support. Pearlene also provided emotional support, mental health education, and the benefits of receiving individual therapy. The patient was initially in the Contemplation Stage of change regarding his mental health. The Contemplation Stage is when a person is aware that a problem exists and is seriously thinking about overcoming the problem but has not yet made a commitment to take action. Pearlene contacted the patient after office hours due to his work schedule which helped gain the patient’s trust and helped the engagement process. Pearlene taught the patient effective coping and problem-solving skills to help him effectively manage his life stressors.
After weeks of routine outreach working with the patient, he eventually moved to the Action stage of change where he decided to take the necessary steps to work on his psychosocial and medical problems. During the Action Stage of change, the patient took steps that included replacing his negative thoughts with positive thoughts and focusing only on things he had control over. The patient finally agreed to a referral to a Trinity Health of New England Behavioral Health provider to continue the work on meeting his health and wellness goals. The patient’s goal for therapy was to learn how to be happy and how to be more assertive. The patient gained a lot of insight. He became optimistic about his future and his level of functioning greatly improved. The patient requested to work with Pearlene for a little longer than the average 3-4 months. Pearlene honored his request and had him identify a time-sensitive goal to achieve within the following 30 days.
The patient shared his long-term goal of attending a GED (General Educational Development) program toward obtaining a U.S. high school level education. The patient researched the GED and enrolled within 30 days. He was immensely proud of himself because this was a goal that he had thought about for many years. During the last outreach call with the patient, he reported buying a new pair of prescription glasses and a desk in preparation for school. The patient also invited Pearlene to attend his graduation in the future.
As demonstrated by this patient’s story, physical and mental health are interconnected and should be accurately assessed and treated simultaneously. The patient’s culture played a significant role in how he viewed mental health and sought behavioral health therapy. Katherine and Pearlene respected and honored the unique qualities of the patient and sought to improve his health and overall well-being. With their support, the patient has shown that “you are never too old to achieve your goals.” 
