Eleven ED visits down to zero
A 67-year-old with CHF and diabetes had 11 emergency department visits in one year. After transitional care, home monitoring, and a fixed 7-day post-discharge follow-up, the next 12 months produced zero.
Member
Mr. Alvarez
Who we help
Adult High Utilizers
Location
Stanislaus County, CA
Timeframe
12-month program
What changed
The outcome for Mr. Alvarez
11 → 0
ED visits year over year
Zero in the 12-month program year.
9.4 → 6.9
A1C
Sustained across two follow-ups.
0
30-day readmissions
Across all subsequent admissions.
100%
7-day post-discharge follow-up
Meeting the HEDIS transitions-of-care measure.
Where things started
The situation.
Mr. Alvarez was flagged by his health plan's utilization team after his 11th ED visit — most for CHF exacerbations linked to medication and dietary gaps between visits.
“For years the ER was my doctor. Now I have a nurse who calls me in my language before I even know I'm slipping.”
The hard part
What stood in the way.
- 1
CHF with recurring fluid overload episodes.
- 2
Type 2 diabetes with A1C of 9.4.
- 3
Living alone; adult children out of state.
- 4
Limited English proficiency slowing every clinical encounter.
Our approach
How we built the plan.
Step 1
Bedside engagement during his next admission — not phone calls after discharge.
Step 2
Bilingual RN care manager holding a 30/60/90-day cadence.
Step 3
Home weight scale, BP cuff, and glucometer with daily readings triaged.
The support
What we actually did.
- 01
Admission — Bedside handoff
Care manager met him in his hospital room; discharge plan built with the inpatient team; 7-day follow-up booked before discharge.
- 02
Days 1–30 — Transitional care
Home visit Day 2; daily weight readings; diuretic titration coordinated with cardiology.
- 03
Days 31–90 — Chronic disease management
Weekly RN calls in Spanish; nutrition coaching; A1C dropped from 9.4 to 7.6 in 90 days.
- 04
Months 4–12 — Self-management
Biweekly check-ins; medication reconciliation at every plan change; no CHF exacerbations requiring the ED.
Behind the scenes
The team and services on this case.
You could be next
Tell us what's going on — we'll take it from there.
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