Patient Voices

Together, They are Living Better
Collectively, Andy and Charlotte Fitzgerald were spending nearly $600 a month on cigarettes. Besides the dollar amount, their habit was taking a toll on their health. Their care manager Kathy Bragdon, RN, at Penobscot Community Health Care, thought they could be successful in kicking the habit if they worked together. “Kathy is super, she makes you feel like you can do anything, and she understands it’s not going to be a piece cake either,” shares Charlotte.

Charlotte, a school bus driver in Old Town for years, developed asthma in her 30s and was tired of always feeling out of breath. “We have four grandchildren and I want to play with them without always feeling out of breath and tired.” She uses her inhaler at night to reduce the risk of having coughing fits associated with bronchitis. She’s also had more than her share of pneumonia over the years.

As for Andy, he suffers from COPD. When he started working with Kathy in April, he was smoking 40 cigarettes a day. Now he smokes just four cigarettes a day and is ready to go cold turkey. “You don’t realize what a hold they have on your life until you go to give them up. I am glad Kathy encouraged us to do this together. I don’t think either of us would be successful otherwise.” There was a time not long ago that Andy was on the fire department in Orono which is where the two met. He got hurt in a construction accident and hasn’t worked much since. “I really feel if I can get my disease under control, then I can start getting my life back.”

Andy and Charlotte are both feeling empowered to start living again. The small yet life changing steps they are taking are leading them both back to school. “I want to do something with my life – leading by example for our grandchildren so that they can be whatever they want to be,” smiles Charlotte. She is hopeful she will be attending a community college in the fall to study graphic design. Andy is also applying to get into school. ‘If it were not for Bangor Beacon and our care manager, I don’t know if we would have ever dreamed this big and had the support to make the changes we need to in order to get healthy.”

When April Loring came to Penobscot Community Health Care (PCHC) she was very sick. “I just lost a friend due to complications from diabetes and additional health issues.  I did not want that to happen to me,” April shares through tears. April was overweight, had high blood pressure, high blood sugar, and was depressed.

Wendy Perkins, RN, was quickly assigned as April’s care manager. They meet twice a month and when April needs extra guidance, she calls in between appointments. “I really see myself as helping people with self management,” says Wendy. The Bangor Beacon care model allows care managers to spend more time with their patients so they can listen to what is going on and help address concerns. They also connect them with resources and show them different ways to go about changing their health issues.

“Every patient is different, for example April loves to read information about her particular diseases – so I always make sure to have literature for her. This is really an exciting project because we are seeing some real change in our patients,” smiles Wendy.

April is feeling better than she has in years. So far, she’s lost more than 50 pounds, her blood pressure is normal, and her blood sugar is coming down. “I no longer eat one big meal a day, I know now I have to eat small meals throughout the course of the day. I can sit on the floor with my niece and play – I couldn’t do that a year ago! My new motto is ‘get up and go’,” laughs April.  When April first walked into PCHC it was with tears of sadness and fear, now she cries tears of joy at a life she is taking back.

Jet Setting to Limit Setting

Belinda Wee has seen the world, literally. She is a native of Singapore with a hotel management degree from Purdue University and a PhD in Education from University of Minnesota. She worked in China, Australia, Malaysia, and most recently in Augusta helping employees of MaineCare adapt to change, in addition to being  an Adjunct Professor at Husson University teaching a Human Resource Management class for their MBA program. “I love learning and sharing what I know - I really enjoy life.”  

It didn’t come as a complete surprise in 2004 when Belinda was diagnosed with diabetes. “I had all the typical symptoms, insatiable thirst, exhaustion, and I was going to the bathroom often.” She knew the warning signs because many members of her family also suffer from the disease. Despite that, Belinda tried to avoid her diagnosis but over time it was unavoidable and  catching up to her. “I was in denial for years, I wasn’t eating right, I was under a lot of stress and it was getting worse almost every day.” Not too many of her friends knew about her struggle, the fewer that knew the better it was as far as Belinda was concerned. “In my culture, it is considered rude to say no to people who offer you food, and so many gatherings with friends are around meals.”

Belinda’s quality of life went from jet setting around the world to having to take insulin in the morning and at night and wearing compression socks to keep the swelling in her legs down. “My A1C was 9 and no matter what I did my diabetes was getting worse.” In an effort to control her weight and get a handle on her diabetes Belinda walked a mile loop three times a day and eating more whole grains in her diet.  Nothing was working. That’s when Belinda decided to sign up for gastric bypass and in doing so her physician at EMMC’s Center for Family Medicine introduced her to Debbie Grover, RN, care manager. “Debbie helps people by being a person herself, she really cares about me and wants me to be better.” An immediate connection was made and the two of them set goals and decided on a plan for Belinda to get her disease under control and prepare for her surgery. “She made me accountable, during our weekly conversations I had to read my blood sugar levels out loud to her and explain why they were high.”

Over the course of the year, Belinda slowly but surely took back her life and learned how to make different and better choices. “Debbie encourages me every step of the way and is always available for questions. I don’t know if any of this would be possible without her.” Belinda had gastric bypass in October of 2011.Her A1C is down to 6.6, the lowest it’s been in five years. She only takes insulin when she needs it and no longer has to take her oral medication. “I feel alive again; I have the energy to do all the things I love, like volunteering at the youth program in my town.” Belinda is taking charge and not willing to go back to the way she was and she credits her success to her care manager who continues to support her as she learns to live healthier, diabetes and all!

Getting the Support She Needs
Peaceful and content is how you could describe Charlotte Bickford as she sits in her glider sipping a cup of tomato soup on a chilly winter’s day. It’s hard to imagine that her life hasn’t always been this way. “We grew up very poor, my four siblings and I picked potatoes to buy our clothes, it was a hard life but we were together, we were close, and we made the most of it.” Charlotte’s family lived on a potato farm in northern Maine her mom cleaned the home and prepared the meals for the owner’s family while taking care of her own children. They were all pretty healthy growing up, just colds and the occasional bumps and bruises. But that was all about to change – Charlotte married young and had six children in seven years and was coming down with pneumonia yearly. “When you have little ones around, a husband in the service and you’re far from home you can’t slow down, you just buckle down and do what you have to do.”

Fiercely independent, Charlotte managed to raise her children and provide a loving home. She’s never been one to give too much energy to things that she can’t control and she tries not to spend a lot of time thinking about how frail her body has become. “I have always taken care of myself and it kills me that now I can’t even vacuum, make my bed, or do my own laundry.” She’s never smoked, yet she has chronic obstructive pulmonary disease (COPD), she’s never drank and she has liver failure, diabetes, and congestive heart failure. “I have more support now than I ever had – having a care manager brings you peace of mind.”

Debbie Grover, RN, care manager at EMMC’s Center for Family Medicine, knows Charlotte well. She was the first Bangor Beacon Community patient she enrolled in the program. The two women talk weekly about how Charlotte is doing, how her test results are, and have developed a nice friendship. “Charlotte fell recently and wasn’t able to get to a phone, so I helped her get Lifeline in case that ever happens again. I also am trying to find her a new place to live – as her diseases progress the few stairs she has to climb to get into her apartment are all but impossible for her to do.” Connecting Charlotte to community resources, working closely with her provider to make adjustments to her medications, and being the calm voice on the other end of the phone while Charlotte learns to manage her symptoms has been invaluable. Prior to care management Charlotte was being admitted to the hospital about three times a year – in 2011 she only had one admission. “I think we are keeping her at home, where she wants to be, she knows we are on her side and she calls us and gets help long before it becomes an emergency.’ Part of what makes Debbie’s job easier is the available health information technology. “It makes working as a team with other providers easier – we can stay on top of problems and make decisions based on the whole patient.”

 Charlotte finds things to be thankful for each day and she knows because of her doctor and care manager she is as healthy as she can be.

“I was so close to dying and I am not ready to die,” smiles Crystal Hoggard as she sits in her one bedroom apartment just miles away from a nursing home that she lived at for nearly three years. It’s no surprise that she developed diabetes. Both of her parents died from complications from the disease and most of her family is living with it. Crystal admits she was not even trying to manage her disease and slowly over time it was ravaging her body. When Crystal was admitted to the nursing home, she weighed 95 pounds with blood sugars in the 600s. “I had just given up. It didn’t seem worth fighting anymore.” It was a choice that nearly cost her everything, including her two young daughters.

However, it was the love for her girls that made her change her mind. When their visits started becoming shorter and more infrequent, Crystal decided she needed help. The Bangor Beacon Community’s approach to disease management came at the right time to make a big a difference. Crystal met Wendy Perkins, RN, care manager at Penobscot Community Health Care, and it changed her life, her focus, and gave her the incentive to fight. “Wendy said to me, ‘if you want to see your girls graduate from high school, you need to help yourself.” The two women meet weekly and talk over the phone whenever Crystal has a question. Crystal learned how to properly use her insulin, which made a big difference. She also stopped eating so many sweets and fried food. She learned to bake and steam her meals. “At first that was very hard, but now I don’t mind the taste.  I even eat fresh vegetables now.”

The changes were small at first yet, pretty quickly Crystal was seeing some big quality of life improvements. “I have so much energy now. I can actually make my bed and get dressed all by myself. I can walk without my cane and my walker.”  The new and ever improving Crystal is reaping so many rewards from her hard work, the best of which is more time with her daughters. “I don’t want my girls to end up like me – I am doing things differently for them.” No more soda and sugary snacks are at the house. This is the new way of life at the Hoggard home. “I want them to be healthy and it starts at home. I see that now.” 

This is just the first chapter in the new book of Crystal, she wants to continue getting better so that eventually she can not only care for her daughters full-time, but she can also get back into a restaurant as a cook again. “I don’t believe any of this would be possible without the support of my care manager. She helped me believe in myself again.”

“My husband is at home with me, where he belongs,” whispers Bonnie Daugherty. Prior to enrolling in the Bangor Beacon Community, David was spending nearly every other month in the hospital. “He is 75 years old and I want to spend as much time with him as possible,” shares Bonnie, his wife of 46 years.

The past eight years have been very hard on the Daugherty’s as David has been struggling with his health – he’s been diagnosed with both congestive heart failure and diabetes. Joanne Reinzo, RN, at Penobscot Community Health Care works closely with David to help him improve his health, and in turn, his quality of life, “I teach David a number of strategies  to care for his disease. The improvements he’s made through diet and exercise have provided  some real changes. Since we’ve been working together over the last four months, he’s had no admissions into the hospital.”

Joanne says that working with her patients is now easier than it used to be because of the addition of electronic medical records (EMR) “With the EMR  I have all the information I need right at my fingertips.” Regardless of who David sees for care – a physician, specialist, or a care manager – any diagnosis, treatment, test, laboratory test, or medications are listed in his EMR.

One of the primary goals of the Bangor Beacon Community is to enhance the sharing of medical records among more providers  and allow information to be available no matter where a patient receives care, allowing for more seamless transitions in their care.

As for the Daughertys, they feel they’ve been given a lifeline. “If it can help me, it can help anyone,” smiles David. 

 We All Need Help… It’s that Simple  
“I planned my retirement around being active until I am 80 or 82, and I won’t let anything come between me and that goal,” smiles Dave Small. You don’t have to know Dave well to realize that when he puts his mind to something, he does it. He lives a pretty active life as he hikes, bikes, paddles, and walks looking for creatures big and small to photograph. “I find it rewarding and peaceful to be out in nature and capture a wild animal in a moment where they almost have a human quality.” Dave’s fascination with photography started when he was seven years old. “I was on the yearbook staff in school. I produced a photography book while I was in the Navy, and when I was in college at the University of Maine in Orono, I took pictures of crime scenes for the Campus Police.”

His mind is always racing on how to do things better and easier. His good ole’ Yankee ingenuity helped him build a one-of-a-kind tripod of sorts that allows him to take his camera when he’s riding his bike. “Before when I’d ride, my camera, hanging around my neck, would bang around and hit my legs or my handlebars.” Now using his “tripod”, the camera is stabilized against his chest, and it helps steady his shots. The thought of ever having to put down his camera because he didn’t take care of chronic disease was not a chance Dave wanted to risk.

Eight months ago when Dave met his care manager, Erin Horne, RN, at Orono Family Medicine, he was motivated to make some changes. He had been taking one medication for years for his diabetes, but in January his blood sugar levels went up and it meant he would need to add a second medication. “I was willing to do whatever it took in order to stop taking that second one.” Erin seized the opportunity to explain the effect of diet and exercise to Dave. “We talked about the importance of monitoring his blood sugars daily so that he could start seeing how his food choices affect his blood sugars,” shares Erin. It didn’t take long for Dave to realize how writing down his meals and blood sugar readings made him accountable. “It’s easy for it to be out of sight, out of mind, but when it’s right in front of you, you can’t avoid it anymore.” A few months later, documenting his meals and blood sugar levels had become a habit for Dave. “He is making great strides in gaining control over his diabetes.”

Watching her patients turn a corner and become more in control of their disease is why Erin became a nurse. “I believe in Bangor Beacon’s model of care. It’s what made me apply for the position as a care manager. I know that with support and education patients can learn to be self-sufficient and lead healthy lives.”

As for Dave, he readily admits that when he was ready to tackle his disease, he needed help. “Thanks to Erin, I am making better choices on a daily basis, and I can see the benefit of tracking my food and exercise.” Dave and Erin went from talking weekly to every few weeks. His blood sugars are getting better each month, and he is reaching his goals. Dave has no intention of letting his diabetes prevent him from living every moment to its fullest. To see some of his handiwork, check out the Saturday edition of the Bangor Daily News Outdoor section. Those are Dave’s wildlife photographs!

Debra Twitchell has never taken her health so seriously. As the head cook at an assisted living home, she sees first-hand the importance of a well-balanced diet. “I knew I was overweight, but couldn’t really find the motivation to do anything about it.” That was until a trip to Alaska to visit her daughter and grandchildren. “I ended up in the emergency room with kidney stones and when the doctor came in to talk to me he started talking about diabetes – I didn’t know even know I had diabetes.” It was a wakeup call that Debra took very seriously. “I had a friend who died in her early 50s because she didn’t take care of her diabetes. I wasn’t going to let that happen to me.”

When Debra got back to Maine she immediately put herself on a very restricted diet, based on the same menus she made for the diabetic patients where she worked. “My goal was too high at first and at some point I would have given up.” That’s where having a care manager made all the difference. Kathy Bragdon, RN, at Penobscot Community Health Care, worked with Debra to create obtainable and lasting goals. “Kathy had me combine diet with exercise, and as a result I have lost 150 pounds. I can walk around the mall and shop without having to stop and rest in between stores. I can lift the 50 lbs of potatoes and flour when they get delivered at work. It’s really awesome.” Debra is doing so well she only needs half the medication she used to take and her monthly check ups with Kathy are now every two months. 

Getting her diabetes under control was just the tip of the iceberg. Thanks to her relationship with her care manager, she is now getting her recommended yearly exams and mammograms - something she has not done in 25 years. “I feel great and I am dedicated to losing another 50 pounds, keeping my blood sugars where they’re supposed to be, and having fun with my grandchildren.”

The Family Plan to Better Health
The Savoy’s have always taken their health seriously, even before Diana’s surprising heart attack two years, ago at the age of 52. Yearly checkups and having a relationship with their providers at St. Joseph Internal Medicine has always been important to them. Within the last few years Diana and Rick both started having their blood sugar tests come back high and then increasing to unsafe numbers. “We have friends in advanced stages of diabetes, and they aren’t doing well. We don’t want that,” shares Diana. Working together with their healthcare providers they came up with a plan and Jessica Audet, RN, care manager, gladly joined the team.

“It can be tricky working with couples and it doesn’t always work well. These two, however, are a dynamite duo,” smiles Jessica. Diana and Rick were high school sweethearts graduating from Old Town High School in 1975. They have been married for 34 years, so they know each other very well and how to motivate each other. “My wife is my backbone and since we both have diabetes we can really be there for each other and help each other. Jessica made us realize just because we are getting older doesn’t mean we have to get unhealthy,” smiles Rick.

Through humor and dedication the Savoy’s have changed the way they live. “When you have to write down everything you eat and all the activity you do it really changes your perspective quickly,” laughs Diana. The Savoy’s had no idea how much the homemade treats, bread, pasta, potatoes, and candy affected their health. They no longer have those types of foods in their home. When they grocery shop they now have a cart full of vegetables, fruits, and other food that fits their diabetes diet. “Jessica is giving us the tools and education we need to get healthy and we are so thankful for that. We would be lost without her guidance.”

Exercise is also a part of their lives. Diana walks in the mall first thing in the morning on her way to work. And you can catch them both out walking their dogs. Their determination to be healthy is paying off. They both have lost weight and the news gets even better. Because of their changes in lifestyle and diet their grown son has also lost 50 pounds and their granddaughter no longer gets sweets during her weekly visits but rather and apple or a carrot. “We are doing this not just for us but for our family – we are all much healthier and happier now.”

Giving Back Sometimes Means to You
It’s hard to believe that Dorothy Kennedy is 73 years old. She is constantly on the go, whether it’s helping her husband prepare their home for winter, making and serving food for the seniors at her church, or learning a new song on her piano. “Don’t forget about the car, it begs for us to take it somewhere every day,” smiles Dorothy. She and her husband Ed, both born, raised, and still live in Greenbush, met during their eighth grade graduation and have been together ever since. Their four children, seven grandchildren, and four great grandchildren all live within a 15 mile radius. They have a close family and enjoy the company of many good friends.

Dorothy never broke a bone in her life or was ever  in the hospital for anything other than having her children up until she had a heart attack at the age of 56. “It was a shock really; I ignored it because I didn’t really think it was anything.” That health scare nearly two decades ago helped Dorothy develop a close relationship with her primary care office at EMMC’s Orono Family Medicine. “They helped me see the value in getting my yearly checkups and paying attention to what my body was telling me.” Dorothy like many women not only raised four children and supported her husband who worked fulltime at the Air National Guard, but she also worked fulltime at Ames in Old Town until it closed in the 90s. “You have to do what you have to do for your family, I didn’t mind one bit.”

She’s never smoked, never drank but she did enjoy the pick me up of a good candy bar, not knowing her low blood sugars were driving her to need sugar. “Looking back, I can now see I would be shaky and exhausted until I had my chocolate.” Diabetes runs in her family on her father’s side so it wasn’t a surprise when she found out she too had it. For years she tried to manage the disease on her own, sometimes more successfully than others.

The rollercoaster ride of Dorothy trying to navigate diabetes alone ended in October 2010 when she got support from Erin Horne, RN, care manager through the Bangor Beacon Community. “If it hadn’t been for her I don’t know what I’d do.” Through education, resources, and a listening ear, Erin is helping Dorothy take control of her disease. “When someone can talk to you about portion control and how certain foods can trigger your blood sugars it is so valuable.” Dorothy now plans much healthier meals and exercises. She and Ed walk their property every morning and every evening no matter the weather. Erin did more than help Dorothy, Ed is also a diabetic and his health has improved as well. “I might not get any better, but I won’t get any worse.” Neither one of them have any plans of slowing down and they are immensely grateful to know help is only a phone call to their care manager.

The Amazing Shrinking Couple
The Dunbars live a quiet life in Lee, Maine. The town of Lee is just north of Lincoln in Penobscot county. Eric, Wendy, and their 11 year old daughter live just down the road from where Wendy grew up. They decided after they got married 15 years ago that this cozy little town of 900 was where they wanted to live and raise their family. “I can’t think of any other place we’d rather be. We’re very happy with our lives,” smile Wendy and Eric. When Eric was diagnosed with diabetes, their happiness was threatened, and the entire family made a commitment to support Eric by living a healthier life.

“When I met Eric in February of 2011, his AIC was 11.1, which is dangerously out of control,” shares Kathy Bragdon, RN, care manager. The news didn’t come as a surprise to Eric and Wendy. “I noticed he was going to the bathroom a lot during the night. He was drinking copious amounts of water, and he seemed more tired than usual,” says Wendy. “My dad has diabetes and is on insulin and lost his eyesight as a result of not properly caring for his disease. I just didn’t want to admit it might be happening to me.” Determined to get his health under control, Eric was eager to start learning about his disease and what he needed to do to manage it.

“The thing that I think is essential for my patients to do is shape their level of engagement to fit their lifestyle. They decide how three meals a day, plus snack, and exercise fit in. I don’t do it for them,” smiles Kathy. When the Dunbar’s left Kathy at PCHC’s Helen Hunt Center in Old Town, they went straight home and cleaned out their kitchen. “I threw out so much stuff that was making Eric sick: pasta, potatoes, rice, and candy bars.” A new chapter in their lives was starting, and they all wanted to do it together.
Watching what they eat and getting regular exercise produced big changes quickly. Within ten weeks Eric’s A1C was down to 6.3, and the goal for people with Type 2 diabetes is 6.5. “We could not have done this without the help and encouragement of our care manager. Kathy was right there every step of the way answering our questions and showing us examples of portion sizes. Life is good,” laughs Wendy.

Their improved health and quality of life continues. Eric’s lost nearly 50 pounds and Wendy 20. “Every time I see them, they’ve lost more weight. I call them the incredible shrinking couple,” smiles Kathy. According to Wendy, the real test will come this winter.

Eric works for the Department of Transportation. “In the winter, I plow the 12 mile stretch between Howland and Lincoln on I-95,” says Eric. “It’s hard to eat healthy when you are behind the wheel for the length of time that I can be.” Ice cream, candy bars, and soda are the quick and easy things to grab while driving. Together Wendy and Eric are figuring out alternatives so that Eric’s health doesn’t start to decline. “We can’t go back. He isn’t leaving me here all by myself. We’ve been together a long time and we’re not done having fun yet.”

George Crouse, a 65 year old Brewer man, is one of more nearly two hundred patients participating in the Bangor Beacon study. “I have COPD, it caused me to retire early. Doing simple things, like mowing my lawn are a challenge.” George is a patient at EMMC’s Family Practice in Brewer. By becoming a Bangor Beacon patient he is now part of a healthcare team that includes his care manager, Sue Rideout, RN. “Our job is to help coordinate a patient’s care, encouraging them, improving their quality of life, and hopefully reducing the need for hospitalization.”

George smiles when he thinks about the difference Bangor Beacon is making in his life. “I am so thankful for Sue, she calls me and encourages me, and she helps me adjust my activities and is making me feel confident again about my health and my future.”

Lori Newcomb, RN, supervisor of EMMC outpatient care, is excited about the potential the Beacon grant offers our region. “It allows for a collaborative approach to improving healthcare for patients with chronic diseases regardless of where they access care through shared electronic medical records and secure e-mail.”

Bangor Beacon nurse care managers are providing patient education, assistance with self-management, and care coordination.  They agree working closely with a patient, their provider, and others involved in their care, they are seeing improved quality of life for patients.

Telehealth is Good Medicine!
Gerald Button moved to Maine 44 years ago to marry his pen pal. “I was stationed in Panama and she started writing me – we wrote for three years and when I got back to the states I moved to Maine from South Dakota and we were married two weeks later,” laughs Gerald.  To many people this is the beloved Mr. Button, an English, speech, and drama teacher at Brewer High School for decades. “I loved being around the students, they kept me young and entertained.” He was the picture of health until out of nowhere 25 years ago he started having chest pains and ended up having a heart bypass leaving him with one artery. “My dad died of a heart attack at the age of 65 and when I got to be that age, the thought of that consumed me.”

Congestive heart failure and diabetes had Gerald in and out of the emergency room and hospital over the years. This past summer it seemed to be getting worse. “I was in the hospital a few days every month.” The Button’s live 25 miles from the nearest hospital and that alone heightens their anxiety about Gerald health. “What if I am having an emergency will help come in time. My wife and I worry about that.”

Gerald was the perfect candidate for Bangor Beacon’s Telemedicine project. Due to restrictions from Medicare he would not be a candidate for the in-home monitoring option. Bonnie Gagnon, RN, homecare nurse for St Joseph Healthcare, is in daily contact with Gerald. She went to the Button home in late August to set up his equipment and walk him through how to use it. “The initial visit takes about two hours, it allows you to develop a relationship of trust and comfort.” Every morning before ten, Gerald checks his blood sugar, weight, oxygen, and blood pressure. That information goes directly to Bonnie. “This equipment is giving me a great deal of peace of mind. When my numbers are off Bonnie will call me and make suggestions. I am learning so much about how to care for my disease. This program is helping to take the worry out of my life.”

The fundamental role of telemedicine is helping to teach people how to care for their disease. Patients not only put in information daily, but information is also shared with them on ways to better manage their condition. Gerald is more confident than ever how to spot warning signs and get help before a trip to the emergency department becomes necessary. “I am thankful for this program; I know it’s kept me out of the hospital. I hope to very soon get my energy back so that I can get on stage again!”

At 72 years old, Gladys Neptune has seen the world around her change. She’s worked as a hotel maid, taken in hand sewing, and for many years, worked as a certified nursing assistant in nursing homes and hospitals. She has six children and five grandchildren who live all around the country.

A longtime smoker, Gladys suffers from chronic obstructive pulmonary disorder (COPD) and a bipolar disorder which complicates her ability to care for herself, take her medication appropriately, and follow instructions.

Gladys recently enrolled in the Bangor Beacon Community program and works with her care manager, Danielle Reardon, RN, at The Acadia Hospital. Gladys was overwhelmed and her bipolar disorder was contributing to some of the issues with her COPD. She was admitted to the hospital on and off for a nine month period and was unable to follow through on the recommendations given to improve her health.

One problem identified was that Gladys was taking too much of her medication, leading her to become unsteady and prone to falls. Each fall would end with a visit to the Emergency Department. With Danielle’s assistance, Gladys received a much needed electronic medication dispenser and she now receives the right medications at the right times.

Three times a day, her dispenser says, “Time to take your medicine,” and then releases the pre-filled dose in a small plastic bag. Once Gladys takes the medication out, the dispenser says, “thank you.” Since the dispenser was installed, Gladys has not had any admissions to the hospital.

Update: Today Gladys is living in an assisted living facility in Bangor. She is able to take the bus to go shopping, uses her walker less, and hasn't had any admissions to the hospital!

Determined to Keep On Keeping On
Home cooking and entertaining are Jim Pike’s specialties, and he comes by them naturally. “Growing up my house was where all my friends wanted to be. My mom was known for her bread and pastries.” Jim grew up in Corinna, one of five kids. They were an active family - hunting, fishing, hiking, and camping. As Jim got older he ran at least 15 miles a week and practiced karate. “I have a family history of diabetes so I was very aware of my weight, and I wanted to be proactive so the disease might skip me.”

Life was pretty close to perfect in the Pike home. When Jim wasn’t working, he was in the kitchen preparing meals from scratch for his family and friends. “Every Thanksgiving we have 30 people over for dinner. We love to entertain.” All that changed in the spring of 1986 when Jim slipped off the roof of a greenhouse while installing propane tanks and broke his back. “They said I’d never work again. It was very painful.” While Jim worked to get his mobility back, he was also very conscientious about his overall health. In the late 90s during a routine check-up, he was diagnosed with diabetes. “It wasn’t a big surprise, and I took it very seriously.” For the first decade living with the disease, Jim was very much in control. “Through diet and exercise I was able to keep my numbers where they needed to be.”

Over time, however, Jim admits that he became less vigilant about his diet. His job, now more in front of a desk than performing manual labor, was keeping him from being as active. “My blood sugars were steadily creeping up and my A1C levels were becoming more of a concern.” That’s how Jim met Kathy Bragdon, RN, care manager at PCHC’s Helen Hunt Center in Old Town. “Jim is great and he was really motivated to make changes. I just helped him identify some simple things he could do to turn his numbers and health around,” smiles Kathy. The first thing Jim did was buy a journal which meant he had to be accountable for everything he put into his mouth. “I had just gotten to a point where I stopped paying enough attention to what I was doing or in some cases not doing. With the help of my care manager, I am getting back on track,” shares Jim. Since April of 2011 Jim and Kathy have been working together, and changes are definitely happening. Jim has friends with diabetes who don’t take the disease very seriously, and he worries about the day it catches up with them as it did with him.

“I am committed to living healthy with my disease. I am walking three times a week again, and I’m vigilant about making the right food choices. Life is a lot fun. I love my family, and we have a lot of friends. I don’t want to cut it short.”

Changing Her Relationship with Food
Jean Belanger gets a twinkle in her eye when she talks about her childhood in Jonesport. She is the second youngest daughter of five girls. She was raised in a close-knit family by her dad, the town’s Barber, and a stay at home mom. “We had so much fun as kids and we really enjoyed each other.”  Growing up Jean and her sisters were always on the go. “I am surprised there were any sidewalks left in town. We roller skated so much,” laughs Jean. When they weren’t doing that, they were swimming, riding bikes, building forts, and in the winter they didn’t stop either. They were ice skating and sledding. “My mom made everything from scratch and we ate lots of fresh fruits and vegetables, so we were healthy and active.” However, being healthy took a backseat to being thin the older Jean got. “It was the 70s being rail thin was the look we all wanted, regardless of the cost.”

Jean spent decades being very critical about what and how much she put into her mouth. She danced a tight rope between bulimia and anorexia up until nine years ago. “That’s when I had a quadruple bypass, then five years ago I was diagnosed with diabetes, and two years ago I had a heart attack.” Jean was trying to juggle her disease on top of losing her only son and getting injured on the job. But it wasn’t going well. In fact in many respects her diabetes was growing more and more out of control. When her physician suggested getting some help, Jean accepted it.

“Wendy changed my life.” When Jean met Wendy Perkins, RN, care manager at PCHC, a bond was instantly formed. Jean opened up to Wendy like she was an old friend. “She had many reasons to be concerned about her health: cancer, heart trouble, and diabetes all run in the Belanger family. Jean’s parents and two sisters all had diabetes,” shares Wendy. Both women agreed they were going to work together to fight the disease so that Jean could get back to living her life on her terms.

“Jean regularly had blood sugars in the two and 300s in June. That’s when she and I first started working together.” Wendy provided literature for Jean to read so that she could better understand her disease. Wendy also worked with Jean’s provider to get her medication changed because it was causing unnecessary weight gain. “Every step of the way Wendy is right there providing encouragement, guidance, and support. She is like a breath of fresh air.” Jean was brought to tears in August when her blood sugar test results came back and they had dropped by 100 points. “I was so overwhelmed, I didn’t think I could do this but I am, and I’m getting better all the time.”

Jean is learning how to change her relationship with food so that she can eat properly to nourish her body. “Choosing the right food and right portions makes meal time easier,  and if I want a treat, I can have that, too, in moderation.” Jean is determined to live a long healthy life with diabetes, and she is thankful every day for care management. “Slowly but surely I am getting stronger, and with Wendy by my side, I know one day I will again be able to walk around the cemetery where my son is buried. I can do this.”

When Good isn’t Good Enough
Sixty four year old Kyle Yoder made his living as a geologist working in oil fields in the most remote parts of our country. “There were no restaurants or grocery stores nearby so for weeks at a time I ate canned foods and white bread and the only exercise I would get would be to walk a few hundred yards to do sample testing.” Kyle would live like this for months at a time away from his wife and son. “It’s what I had to do to provide for my family.” Kyle had no idea the damage he was causing his body by living the sedentary lifestyle. “Each spring my son and I would go on these incredible hiking trips out west and I never felt like I couldn’t do anything or that I couldn’t keep up.”

However, that changed during a routine eye exam to keep his pilot’s license. “My doctor looked into my eyes and told me I needed to go see my family physician. He was pretty sure I had diabetes.” The news took Kyle a week or two to absorb. No one in his family had diabetes although looking back he remembers being lethargic. ‘I wasn’t happy with the diagnosis. It felt like the first piece of marble chipped off my theory that I was invincible.”

Over the past decade Kyle did the bare minimum to take care of disease, he checked his blood sugars on and off and took his medication as prescribed.” My life was hectic and I didn’t really want to stop and think about it.”  And to complicate things even more, Kyle and his wife moved to Bangor eight years ago to help their son and daughter-in-law with their two infant children while they pursued their doctorate degrees. “I was commuting from here and frankly, I thought I was doing good enough.” Kyle was gaining weight and he was suffering all the side effects that come with blood sugars going unchecked. “Doctor Kevin Miller at Husson Internal Medicine is great.  He really listened to me and would adjust my medications accordingly and when he suggested I work with a care manager, I agreed to at least give it a try.“

When Kyle first met Kathleen, RN, care manager, a team was formed. “When I first started working with Kyle, his blood sugars were quite high and he was initially reluctant to keep a food diary and check his blood sugars”. Now it’s a part of his daily routine. “It made me confront what I was eating, and I could see a direct correlation between my choices and my blood sugar levels” Adjustments were made by Dr. Miller in his medications, and Kyle’s blood sugars came down beautifully.  

“Care management is the best thing that happened to me and my disease. I was given a resource, Kathleen, to help me connect the dots and learn how to be successful.”

Jessica goes the extra mile. She listens and gets to know you. She’s kept me out of the hospital once already and I just started working with her two months ago,” shares one of her patients, Larry Guy.

Larry’s diabetes diagnosis opened the door for him to work with Jessica. He will be the first one to tell you he was a “frequent flier” at St. Joseph Hospital. Larry has respiratory and circulatory conditions that also require medical attention. “I have seen a lot of healthcare providers during the last 15 years and, to be honest, I wasn’t expecting a lot from Jessica. But I was wrong. I have never had an advocate like her before.”

Jessica treats Larry like she does all of her patients: with compassion and an open mind. “What I’m really doing is collaborating with them – I am not here to hold their hand. I won’t tell them what to do - I help them identify ways they can make changes,” explains Jessica. By identifying one or two changes that they can make in their daily routine, they will notice change, and that is where success starts and that’s where Jessica helps her patients focus. Dr. Krause can’t say enough about Jessica and the changes she’s making at both the practice and patient levels. ‘She is competent, positive, and looks to the providers to see how she can best work with their patients to make their lives better. She is an asset and has transformed the way we give care.”

You can’t help but smile when you stop by Lisa Allen’s home. On a quiet road in Hudson you can often find her out with nature. Each spring she and her husband plant a garden, complete with a pumpkin patch for their grandchildren. They also get up to seven fresh eggs a day courtesy of their new chickens. “It’s peaceful and we really like it here,” smiles Lisa. The mother of three grown children, Lisa has many reasons to want to live a healthier life. “I just wasn’t feeling right. It was horrible. I felt like I was perpetually exhausted.” Diabetes runs in her family so it was no surprise when 20 years ago she was diagnosed with the disease. However, it wasn’t until October 2010 that she actually took the disease seriously. “I called myself a “deny-abetic.”I really just hoped I would wake up one day and it would be gone.” Lisa struggled with managing her blood sugars – they were regularly in the in the 3, 4, and 500s. It wasn’t until her doctor told her “if you don’t start behaving, you could lose your driver’s license,” that Lisa finally took her diagnosis seriously. The Bangor Beacon Community approach came along at just the right time to make a huge impact.

Cynthia Herrick, RN, care manager, understands how a chronic disease can be difficult to understand and manage. “Diabetes is one of the most complex chronic diseases because everything affects blood sugar, everything from thing from diet to exercise, stress, and even other health conditions.”  Lisa found a great sense of comfort and new found confidence improving her health. “Cynthia broke down what I needed to do and made it doable. I am very meticulous with my journal, writing down what I eat and how my body responds to it.” Everyone is different so there is no “one size fits all” with diabetes. Lisa learned through trial and error what foods to avoid and how much of something her body can handle. “Because of Cynthia’s help, I understand how to combine diet, exercise, and medication in order to feel better. I feel better and have more energy than I have in years!” Lisa is doing so well that her weekly conversations with Cynthia are now every two weeks and better yet, Lisa is now eligible for a gastric bypass because of her improved health. “I really want this surgery. I don’t like being tied to medications and I want to live a long healthy life. I am just so thankful I had someone to lean on and teach me the ropes. It made an impossible task possible.”

Cynthia is not surprised at the success Lisa is having, she knew it would be a matter of time. “Lisa is so motivated and open to suggestions. Change can’t happen without willingness.” 

Marcia McManus is a transplant to Maine from the Seattle area, moving here a year ago January. “My sister and I are both widows and she was living up here by herself and asked me come live – and I said yes,” smiles Marcia. Life for Marcia has never been easy, she lost a son to cancer at the age of 12 and both her parents died young from cancer and heart problems. She’s always worked hard to provide for her family working for 30 years running a local dry cleaner. “I had my first heart attack in my 40’s.” So, the thought of moving to Maine for some peace and quiet made perfect sense. “Because I have so many health issues I was worried about leaving my doctors at home – but I shouldn’t have, I’m in great hands here.”

When Marcia first arrived in the Bangor area she was in and out of the hospital with high blood pressure. At her first appointment with her newly assigned primary care physician  she heard about the Bangor Beacon Community.  “I am thankful for this program. I never had this kind of follow up or attention before.” Kathleen Bates, RN, was assigned as her care manager to help her with her COPD and congestive heart failure. Marcia was smoking two packs of cigarettes a day when she first started working with Kathleen. She is now down to just a few a day with the intent on quitting soon. “Kathleen has such a good manner, she’s compassionate, and she knows what she’s doing,” shares Marcia.

Through weekly phone calls Kathleen keeps a close eye on Marcia’s breathing, blood pressure, and weight, reporting to the doctor any changes, so that medications can be adjusted. Kathleen also was able to get visiting nurses and a physical therapist to Marcia’s home when she was at her weakest.

The good news it all seems to be working, Marcia has not been to the hospital in months and is getting stronger everyday. “You know what they say – you can’t keep a good woman down.” Marcia wanted a simple quiet life and that’s exactly what she is getting. “I love being here with my sister, we laugh, we talk, we cook, we eat, and soon I’m going to grow a little garden.”  

Margaret Taintor enjoys a good visit. If you are fortunate enough to spend time with Margaret, the minutes fly by as you find out about her life. She was born December 18, 1913 in Massachusetts, “We were poor but my brother, sister, and I found plenty to do – we’d walk for miles for a good sledding hill when we were kids,” remembers Margaret. Margaret was too busy enjoying life to get married young she says, “I was nearly 40 when I finally said “I do.” I met him square dancing and we continued to do that for years together.”  Having no children, it was easy for Margaret to move to Maine in 1971 following her divorce. She moved in with sister whose husband had recently passed away.

She and her sister have been on many adventures as they drive around eastern Maine exploring all the little towns along the way. Her favorite thing to do was eating at the local diners, especially in Dover-Foxcroft and Dexter. When her sister passed away a decade later, Margaret continued to live life on her terms. Her desire for friendship and adventure has not waned even with her current health status. “I had to give up my car 12 years ago - that was the hardest thing I have ever done.” Nearly blind and suffering from congestive heart failure, Margaret still lives alone.

“She was hospitalized last fall and we thought we were going to lose her, but she has become stable with a lot of TLC. She truly is a delight,” smiles Kathleen Bates, RN, care manager.  Kathleen monitors Margaret’s breathing and medications during a weekly phone call. Kathleen knows by her breathing when Margaret needs to take her diuretics. Margaret is doing very well and has had no readmissions to the hospital since she’s had Kathleen as her care manager. “She really is an inspiration being able to live alone at 97 and unable to see well. I feel privileged to know her.”

Margaret doesn’t know what all the fuss is about; she’s more interested in how the Red Sox will do this season. She’s counting down until opening day. “I watch Sports Center, the Red Sox, the Patriots, I knit a bit, and I enjoy when the weather is nice and I can sit outside in the morning and sip my coffee,” smiles Margaret as she looks forward to the days ahead.

Getting Back in Tune
Mercedes Nelson has a spirit that is uniquely her own. She is a vivacious 22 year old who has big dreams and is willing to work hard to achieve them. She is also a single mom to a three year old son, a member of the honor roll as a college student, and she suffers from asthma. “My shortness of breath and not being able to be as active as I want to be had me really becoming edgy towards my family and friends, and most importantly to my son,” shares Mercedes.

She was diagnosed with asthma in high school when she struggled to breathe during track and basketball seasons, to the point that she would become light headed and have a great deal of pressure on her chest. “I was so frustrated, and I kind of gave up a little bit and stopped doing some of the things that I love, like exercise.”

Smoking a pack of cigarettes every two or three days wasn’t helping her condition either. “I know quitting isn’t easy and everyone has their own incentive. Mercedes needed to find hers,” shares Kathy Bragdon, RN, care manager at PCHC’s Helen Hunt Center in Old Town. Kathy and Mercedes started working together in early spring of 2011, and Mercedes stopped smoking on April 24. “I realized how much I was losing by doing that. I would have to go outside away from my son to smoke, and it was affecting my singing. It just wasn’t worth it.”

With smoking no longer an issue, the next step was helping Mercedes get control over her asthma so that simple things, like playing with her son, didn’t take her breath away and so that she could hold a note and perform with her band.  “Before Kathy, I was only seeing the doctor when I needed my prescriptions filled. Now, I’m learning how I can better manage my asthma and not let it control my life.”

Slowly but surely, Mercedes is seeing positive changes. She learned that she was using her inhaler the wrong way. “Every day I am becoming more confident that I can live a full life. I am just taking baby steps.” With Kathy by her side each step of the way, Mercedes is optimistic her big dreams are soon going to be a reality.

If you met Mike Labun, you would think he is the picture of health. He runs marathons, is active in the lives of his three children, is a supportive husband, and is a local banker for nearly two decades. He grew up in Millinocket where his father was a school teacher and his mom a nurse at the local hospital. Mike and his wife Suzanne, a Maryland native, knew Maine was where they wanted to raise their children. By all accounts, the Labun family was a traditional healthy family. Until the morning of Mike’s 42^nd  birthday. “I woke up not feeling well. I was light-headed and my arm was tingly. I thought I was having a heart attack.”

When Mike got to the hospital, a whole litany of tests were performed to try to determine what was causing his symptoms. “They all came back normal.” However, a red flag was raised with a blood sugar test and Mike was told he needed to follow up with his doctor, which he did and was later diagnosed with Type II diabetes. “It didn’t add up, even with diet and exercise, I wasn’t changing my blood sugar readings at all.” As it turns out, Mike suffers from Type I diabetes. “It was a shock. No one in my family has diabetes and Type I diabetes is generally hereditary.”

Needless to say, the past two years have been eye-opening for Mike. “I feel like I have become a bit of a chemist. There is so much to absorb and a lot to deal with it.” Mike welcomed the help of Cynthia Herrick, RN, care manager. “I needed someone to talk to, someone to help me establish a diet based on how much I exercise and the already healthy way I eat.” At first, Cynthia called Mike weekly answering questions, providing information, but most of all building his confidence that he could live with this disease and be healthy and happy. “No one is more interested in me keeping my eyesight than me – I just needed someone to help me get control back.” And that is exactly what Cynthia helped Mike do. Mike uses insulin four times a day based on how many carbohydrates are in his meal. “I found a great app for my phone. I punch in what I’m eating and it comes back with a carb count which makes this much easier to figure out.” So far, so good for the Labun family, Mike is still up running nearly every day, still cheering on his kids as they play sports, still working fulltime, and continuing to enjoy time with his wife. “A chronic disease diagnosis is scary. Add in young children and a wife, and it can almost cripple you. I am so thankful for this program and my care manager. Cynthia is only a phone call away. Because of her guidance and support, I can see that life can still be all that I want and more.”  

A Circle of Support is Where Change Happens
Seventy-four year old Patty Tapley grew up in England during war time. “People were more concerned about living through the day than they were about helping others” says Patty, who, from a young age, learned to rely only on herself for survival. She’s always felt alone when it comes to the daily struggles of life. “It’s a hard habit to break, being as independent as I always have.” Her British accent and sunny disposition leave the impression she’s upbeat and has everything under control, but that’s not really the case.

Patty was diagnosed with chronic obstructive pulmonary disorder (COPD) a decade ago and up until recently never really had a good handle on how to live with it. “I smoked a pack a day from the time I was 14 until I was around 55 and then one day I just gave it up.” But she continues to live with the side effects of smoking all those years. “Imagine, if you can, sitting watching TV, doing absolutely nothing and suddenly you are struggling to breathe. That’s what this disease is like.” During those attacks Patty would be riddled with fear that help wouldn’t arrive in time. “I was going by ambulance to the hospital up to nine times a month for years.”

That, however, has all changed. Patty is a Bangor Beacon patient at EMMC’s Orono Family Medicine. She is working with her provider, Kevyn Comstock, MD, and care manager Erin Horne, RN. Together, these ladies are making great strides in reducing Patty’s anxiety and improving her overall quality of life. “I have never met Erin in person, but I feel as though we are great friends. She calls me once a week to see how I am doing. She is also available anytime I am struggling or have a question.” Patty is learning how to live with her disease and manage the symptoms in ways that don’t require a hospital visit. “I haven’t been in an ambulance or an emergency room in nearly a year.” Patty gets the peace of mind she needs by calling Erin to find out ways to reduce her symptoms before they become an emergency. “The education and the tools are immensely helpful. With these two women on my side caring about me, how can I fail?”

Patty knows COPD can’t be cured and now she knows it’s a disease that doesn’t have to limit your life and isolate you. “I still struggle with breathing and doing things but not nearly like I use to and it keeps getting better – for that I am grateful.”

Reginald (Reggie) Sholler wasn’t always up for having company. In fact, during the past couple of decades he became very reclusive. “I just didn’t see any value in myself and thought why anyone would want to be around me?” shares Reggie. Legally blind and not very mobile, Reggie isolated himself from the world. He was diagnosed with diabetes 20 years ago and more recently with congestive heart failure. He is also being treated for bi-polar disorder and manic depression. “It was hard to see what my body has become. Not long ago, I was in great physical shape. I was in the Air Force and was a high school track star from Brewer. I thought I was indestructible.” But his chronic diseases turned out to be a formidable opponent that forced Reggie to change his life.

“When I first met Reggie, I thought he may be borderline suicidal. He wouldn’t make eye contact and he thought his family would be better off without him,” remembers Kathy Bragdon, RN, care manager at Penobscot Community Health Center. Kathy has been working with Reggie since November 2010. When they first met, Reggie’s blood sugars were regularly in the 400s, he was drinking a 12-pack of soda a day, using four spoonfuls of sugar in his coffee, and rarely, if ever, drinking water. Reggie also smokes up to a two packs of cigarettes a day. “I played with my diabetes, I would use my medication and insulin to try and off-set my food choices. I knew smoking was bad. I just didn’t care,” says Reggie. Often times, patients with chronic diseases know how to care for themselves, but feel overwhelmed by where to start. That’s why Kathy allows her patients to decide what they want to work on. “It really changes the dynamic of the relationship. It helps put them in charge of taking the necessary steps to better their health.” Kathy feels a positive change is a positive change and fuels people to continue their journey. Thanks to Kathy, Reggie is also going through job training for the blind.

Slowly, but surely, Reggie is seeing some real changes all due to his hard work and Kathy’s guidance and support. Reggie sees Kathy once a month and they talk on the phone weekly. “She is amazing. At my slightest worry or concern, she is right there to help me.” Now he drinks water more than anything else. He is eating more fruits and vegetables, he is taking his medications the way they are intended, and he wants to stop smoking. “I want to see my sons graduate from college, I look forward to being a grandparent someday. I want to lose weight and start building up stamina again so I can actively be a part of my life. I see a light at the end of the tunnel that I don’t think I ever saw before.”

If you attend local theater productions you may recognize Stephen Estes. “I caught the acting bug in 1998 when I was cast as a tenor in EMMC’s Follies,” smiles Stephen. He’s a regular at the Grand in Ellsworth and other local community theaters. Always very active and involved in the lives of his two teenage daughters, Stephen didn’t really notice his weight loss, increased appetite, insatiable thirst, drowsiness, or irritability.  His family sure did - and after six months of his declining health they convinced him to go EMMC’s Walk in Care. “They performed blood work and told me if my blood sugar was any higher – they would have sent me to the hospital.”  Turns out, Stephen had developed Type 2 diabetes. Type 2 diabetes, once known as adult-onset or noninsulin-dependent diabetes, is a chronic condition that affects the way your body metabolizes sugar (glucose), your body's main source of fuel.  When you have type 2 diabetes, your body is resistant to the effects of insulin — a hormone that regulates the movement of sugar into your cells — or your body doesn't produce enough insulin to maintain a normal glucose level. Untreated, the consequences of type 2 diabetes can be life-threatening.

The diagnosis was a year ago and admittedly the first six months was very difficult. “I just didn’t want to accept it; I tried not to pay attention to what I was supposed to do, so I wasn’t really getting any better.” That changed when he became a part of the Bangor Beacon Community. Kathleen Bates, RN, was assigned as his care manager. “In a gentle way Kathleen made me accountable for my health. I wasn’t consistent about tracking my blood sugar readings. Now I practically write a book.” When Stephen started tracking his numbers more closely, it was easier for Kathleen and his physician to adjust his insulin. Kathleen would call weekly until the routine became  part of his way of life, now she calls every couple of weeks. “Kathleen really helped me come to terms with my diagnosis and now I feel like I’m in control of it.”

Stephen says this is the least amount of stress he’s had in his life, in as long as he can remember. Currently, he works for Penquis, and he drives people to and from their doctor appointments. Prior to that, Stephen was a clinician at a group home in the area.

Stephen is happy to share that he is making smarter choices, sleeping like a baby, and is alert and alive again. He credits care management as the main reason why.  

Telemedicine Success!
Sue Grover has a lot to live for and the last place she wants to be is in a hospital. ‘I was ending up in the hospital every few months and for ten days a time.” There’s no denying that Sue has health problems, she developed diabetes in her late 50s, has congestive heart failure, and chronic obstructive pulmonary disease (COPD). “I have been on dialysis for nearly two years since my kidneys completely shut down.” During her stay at EMMC she was enrolled in the Bangor Beacon Community Telemedicine program. Because Sue doesn’t meet the requirements under Medicare as a homebound patient this option was never offered to her in the past.

“What a great program, they really kept an eye on me.” A homecare nurse from Community Health and Counseling Services (CHCS) went out to Sue’s home and showed her how to use the scale, blood pressure, and other monitoring equipment. Every morning for 30 days Sue checked all her vital signs and the information was sent directly to Brenda Boiler, RN at CHSC. Brenda has 40 years of nursing experience, 20 of those years in homecare. During her month of monitoring Brenda along with Sue’s provider helped Sue with a respiratory infection, a spike in her blood pressure, and an extra dialysis treatment due to a rapid increase in her weight. “I think they saved me from going to the emergency room at least three times during that month – and what I learned while being monitored is still helping me.”

A huge component of telemedicine is not only avoiding preventable readmissions but also teaching people how to care for their disease and how to get the proper help before their condition turns into an emergency. “I’m not sure I will ever go on a cruise again with my family, but I want to be at my beautiful home on Brewer Lake with my husband of 35 years, visiting with  my grandchildren enjoying what I have left… to me that’s being healthy.”

Her hobby is intricate, time consuming, and requires a great deal of patience and Sue Press could not be happier about creating her greeting cards again. “When I wasn’t feeling well, I just could not sit down and concentrate on my cards, but now I can sit down for hours and make them,” smiles Sue.

Sue’s health problems started in the late 80s with diabetes, then she developed asthma, and most recently was diagnosed with congestive heart failure. “Over time, my health just kept getting worse. I ending up being admitted to the hospital month after month - it started to take the zest out of my life.” Sue was always very active raising sheep, growing strawberries, taking long walks with her sister, playing with her grandchildren, and doing crafts but her health problems were keeping her inside stuck on the couch.

When Kathleen Bates, RN, care manager at Husson Family Medicine, asked Sue to participate in the Bangor Beacon Community project, Sue thought, “What did I have to lose?” Now she could not be happier that she decided to take part in the project. “When I first started working with Sue back in July of 2010, it was primarily to help her control her diabetes,” explains Kathleen. For more than a decade, Sue’s blood sugar level was all over the place causing many health problems. Kathleen’s goal was to support Sue while she was learning to take back control of her life. In just seven months, Sue was able to get her average blood sugar down nearly a hundred points. “It takes a lot of work to bring your numbers down, but by getting her blood sugar readings every two weeks, her provider was able to adjust her medications,” smiles Kathleen. That is one of the benefits of care management that Sue truly appreciates, the almost instantaneous relationship with her doctor and nurse. “If something is going on I call Kathleen and sometimes within minutes I get a call back – it’s wonderful.”

This summer if you want to catch Sue, you better be quick, with her improved health she has many plans. “I’m going to play with my grandchildren and take a trip to Missouri with my husband to spend time with his family, a trip I haven’t made in a few years because my health was so unstable.” Sue is going to continue her passion of creating one of a kind greeting cards, selling them at the little store in Frankfort just down the road from her home.

Congestive heart failure, chronic obstructive pulmonary disease (COPD), and lung cancer: those are the diseases that Wanda Williams is determined to beat. “If you look back at my life, you would probably think ‘how did she make it this far?,” whispers Wanda. To say her life has been hard would be an understatement, yet she is approaching 70 years old and still as kind and giving today as she was as a little girl. She has suffered immeasurable losses and abuse at the hands of those who were supposed to love her. Yet the one thing no one could take from her was her soft heart and willingness to help others. When Erin Horne, RN, care manager at Orono Family Medicine met Wanda, she was in the hospital. “She was struggling with her COPD and acute renal failure. What I noticed most about Wanda was that she worried so much about those that she loved and not enough about herself.”

Erin took the time to get to know Wanda to understand where she was coming from and was then able to help Wanda identify some steps she could take to improve her life. “The first thing we worked on was building up Wanda’s understanding of her diseases. That way she would have the knowledge and confidence to ask for help long before it became an emergency.” Wanda admits that learning to put herself first is the hardest part of living with her health conditions. “I just want everyone around me to be healthy and happy. I love caring for people.” For the first time in her life Wanda feels supported and determined to live a healthier life. She has been working with Erin since January and is making great strides and has all but quit smoking cigarettes, something she has done since she was seven years old. “I saw a real change after I got Wanda into pulmonary rehabilitation. She loved it and I saw a change in her overall well-being,” smiles Erin.

It brings Wanda great comfort to know that if she is having trouble, she can pick up the phone and talk to Erin. So far it’s helped her from avoiding complications that would put her back in the hospital. “I’m grateful for where I am right now – I am enjoying my life, I am staying active.” Wanda is taking it one day at a time, taking the necessary steps to get healthy and is thankful she has the safety net of a care manager.