Mike Lester, 57, was diagnosed with diabetes in his late 20s. For more than 25 years, he managed his condition, could function without restrictions, and enjoyed good quality of life.
That all changed three years ago when he developed circulatory problems in his legs and chronic obstructive pulmonary disease (COPD). He endured surgeries, complications, rehabilitation stays, and the amputation of his left leg. His day-to-day existence had gone from a normal one to a cycle of medical appointments, treatments, and recovery periods.
In the spring of 2018, Mike’s primary care physician (PCP) with North Shore Physicians Group referred him to Care Dimensions’ Palliative Care+ Program, a collaborative state grant-funded pilot program to improve access to palliative care. Offered in conjunction with curative care, the Palliative Care+ Program gave Mike access to an extra layer of support through monthly home visits by a nurse practitioner and weekly phone calls from a nurse coach.
Mike’s Palliative Care+ team checked in on him regularly to track his progress, offer suggestions, and report findings to his PCP. Although he was at home in Salem, Mike was suffering from multiple, painful open wounds that required dressing changes by a visiting nurse. Calls from the Care Dimensions nurse coach “helped keep me focused on getting better, made suggestions on what I could do differently, and made my pain a bit more bearable,” Mike recalled.
Mike had more obstacles to overcome, however. In early fall of 2018, Mike had a vascular bypass, in which the surgeon replaced a damaged vein in his right leg with a good vein from his right arm. He was fitted for a prosthetic leg and started learning how to walk with it. But, then a series of complications led him back several times to the hospital’s intensive care unit, rehabilitation, and finally back home.
Mike has faced death several times and he’s living daily with the symptoms and complications of a serious illness. But, with the support of the palliative care team, he has bounced back, is home and focused on the future.
Care Dimensions’ palliative care nurse practitioner Jeanne Earle has been working with Mike since November 2018. Before each visit, she checks in with the case manager at Mike’s PCP office who coordinates his care. “I find out what’s going on with Mike, see how his condition has changed since my last visit and how his pain is being managed,” said Jeanne. “I’ll call the case manager again after my visit to let her know if I have any concerns based on my observations of his health and his living conditions.”
Visiting Mike in his home gives Jeanne increased insight into Mike’s condition and how he’s coping with the symptoms of his disease. After noticing that Mike wasn’t getting out much because his walk-up apartment in Salem wasn’t easily accessible for him, she suggested that he move to a new apartment that would be easier for him. In January, Mike moved into a Beverly apartment building that has an elevator and doorways wide enough to accommodate his wheelchair. Now that it’s easier to get out, Mike’s outlook has improved and his stress has decreased.
"Jeanne puts my mind at ease,” said Mike. “It’s like I have someone watching over me. She gets in-depth with everything that’s going on with me. She’s very informative, and if she doesn’t know the answer to a question I may have, she’ll find out, which means a lot. She keeps me on track and is a great member of my personal care team.”
“I’m truly grateful for all the additional support from Care Dimensions palliative care team that has helped me get my quality of life back,” said Mike.
Now that the 18-month pilot Palliative Care+ Program has ended, Care Dimensions is investing more in community-based palliative care to give patients like Mike an extra layer of support that can help them keep the symptoms of their advanced chronic illnesses in check, improve quality of life and ease stress. This expanded model will add the services of nursing and social work to the consult program that Care Dimensions nurse practitioners and physicians have provided since 2002. Depending on a variety of factors, including clinical condition and the patient’s support network, patients will be assigned to one of three programs. Each patient will receive a combination of in-person visits and telephonic support, individualized to their needs. Initially available to patients on the North Shore, the program plans to offer this expanded service throughout our entire service area by the end of 2019.
Palliative care offers a much-needed layer of assistance to patients and families that can reduce hospitalizations and emergency room visits by better managing symptoms at home.Read more
After a hospital stay for congestive heart failure and rapid atrial fibrillation at the age of 91, Phyllis Kransberg of Beverly, MA, discovered that palliative care was just what she needed to help keep her out of the hospital and back on track.
Since 1978, Care Dimensions, formerly Hospice of the North Shore, has provided comprehensive and compassionate care for individuals and families dealing with life-threatening illnesses. As the non-profit leader in advanced illness care, we offer services in over 100 communities in Massachusetts.