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ACO Patient Success Story

The following case study was authored by MetroHealth Care Partners ACO for informational purposes. To learn more, please visit MetroHealth Care Partners ACO at

 ACO Margie

One of the happiest days of 76-year-old Margie's life should have been the day of her granddaughter's graduation. But Margie was unable to attend because she was too worried about running out of her oxygen supply. "I was heartbroken to miss it," she says.

Margie, a Medicare patient, came to the attention of Beverly (B.J.) Irizarry, RN, BSN, and ACO Care Coordinator, at The MetroHealth System's Thomas F. McCafferty Health Center. "I started coordinating care with Margie as a result of one of her recent visits to the emergency room, which were becoming more frequent. She had high blood pressure, anxiety and trouble breathing," says Irizarry. Margie had a particularly tough time in the summer, when the warm temperatures and humidity made her feel as though, Margie says, there was a hand over her mouth. Based on the case reports, Irizarry knew her intervention could help.

First up was getting Margie's high blood pressure and anxiety under control. Further down the road was a visit to a pulmonary clinic for oxygen saturation testing, which showed that she was desaturated at an 88 percent to 90 percent level, causing stress on her heart and impacting the activities of her daily living. She has a history of Chronic Obstructive Pulmonary Disease and was ordered oxygen.

It was a start, but here's where Irizarry and the MetroHealth ACO's follow-up played an important role. "First, I facilitated the delivery of oxygen to Margie's home," says Irizarry. But even after the delivery, Margie arrived for a scheduled visit to the clinic quite out of breath. "She was having trouble connecting the oxygen cylinder to her carrier. The carrier she had been given was too heavy. Further complicating the situation, the cylinders she had received would last only 1 hour and 20 minutes," indicates Irizarry.

"That's why I missed my granddaughter's graduation," explains Margie. "I had stopped going to my church on Sundays, too, which was one of the most important parts of my life. I couldn't get out of the house. I felt confined."

Working with Margie's general family physician, James Misak, MD, Associate Director, Family Practice, a respiratory therapist was ordered to assess Margie's home situation. Next, Irizarry worked with the oxygen supplier to arrange for a Bonsai® oxygen conserving device, which lowers the risk of desaturation when the patient is active, and enables Margie to extend the life of her oxygen cylinder to six hours. "With two tanks, I can be out of the house for 12 hours," Margie asserts.

"B.J. has been a blessing to me," says Margie. "She helped me get through the crisis with my blood pressure as well as helped me get the right oxygen delivery system. I can call her when I need help and she is always there. If I have questions or have trouble getting in to see my doctor, or getting a prescription, B.J. knows how to arrange it. I have a friend in my corner who I can turn to in a hurry. If I'm not sure of something, she explains it to me. And she's helped me use MetroHealth's MyChart patient records system."

"More than that, B.J. is my good friend. She's easy to talk to and understands me," says Margie.

As a Medicare Shared Savings Program Accountable Care Organization, the doctors and health care professionals at MetroHealth Care Partners ACO work together to provide higher-quality coordinated care to their patients, while helping to slow health care cost growth. Improving care outcomes through resources such as care coordinators like Irizarry, play an important role in ensuring care is appropriate, safe and timely.

"Some things seem so little to us but I can see how difficult it is for a patient to navigate," says Irizarry. "I've been working with Margie since the beginning of the year. We have a close relationship based on an open door policy, trust and respect. She knows, as do all of my patients, that if they leave me a message, I will respond to them before the end of each day. I answer every call."

Margie is back to church on Sundays, where she spends almost the entire day. She's involved in the church's music program. "For years, I've helped children learn to play the guitar. Everyone here is part of a loving family. With my new, longer oxygen supply, I feel like I have wings again."

Next up for Margie? A vacation to Alexandria, Virginia, to visit her sister. Irizarry coordinated the reservation of a portable travel oxygen concentrator that helped make it possible. "I wouldn't have been able to go if B.J. hadn't helped me take care of this," says Margie.

Although Margie missed her granddaughter's graduation, she looks forward to future events with enthusiasm. "I have a wonderful doctor and a wonderful care coordinator. And I have five more grandchildren. Now I know I'll have the chance to see them graduate."