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Trinsic Clinically Integrated Network

During a routine monthly call, a patient in Florida tells Taylor Hodges, RN, that he’s run out of insulin. In fact, he’d just learned his specific medication was discontinued. 

He’d already gone without for several days. So Taylor notifies the provider immediately through the electronic medical record. The patient is seen within days and started on a new insulin medication. 

Through their expertise and empathy, Wellvana’s nurses make primary care life-changing. 
Foundational Care provided between in-office appointments at no cost to patients reduces emergency department visits by 17% and monthly medical spending by 8%. 

In a follow-up call, Taylor reminds the patient — who lives alone — that she’ll be calling regularly. “Sure, that’ll be alright,” he says. “I need somebody to talk to besides the dog.” 

“I want to empower the patient by providing knowledge and meeting the patient where they are to take control of their health and wellness," Taylor says. "I go above and beyond to treat each patient with great respect.” 

A patient in California with four stents and serious heart trouble needed education or she was destined to land back in the hospital.

She had support from family but didn’t seem to understand why it was so important for her to follow discharge instructions so carefully.

📞 Initially, the patient was reluctant to share about her diagnosis and talk about symptoms on regular calls with Wellvana Care Manager Van Pham. Then Van began offering education and explaining the rationale behind each treatment.

As trust increased, the patient called Van one day, She inquired about her blood pressure, which was much lower than usual. She wondered whether she should stop her blood pressure medication and confessed that she had already halted her blood thinner because she feared drug interactions.

Van gently reassured her that the medications could be taken together as prescribed and when it would be appropriate to hold a medication. She also asked the patient to start a blood pressure log and update it three times a day. 

💊 After keeping the logs and resuming her medications, the patient’s blood pressure has stabilized. The understanding of her condition is making her a better patient and a healthier person.

A patient in Arizona suffered a stroke. He had to be air-lifted to a hospital in Nevada. Then he was discharged to a family member’s home in California. His recuperation was going to be too much for his elderly wife to handle alone. 
 
He was prescribed blood pressure medication but not given any instructions at the hospital. Now he was in another state without a doctor, and his readings were dangerously low. He was getting lethargic. His breathing had turned shallow.  
 
The family called a new cardiologist. But they were only seeing established patients.  
 
Fortunately, Kristina Miller, RN, with Wellvana was handling the standard discharge management. She reached the patient’s wife and immediately recognized the urgency of the situation.  
 
Kristina placed a priority alert in the EHR at this patient’s home practice in Arizona. Given the life-and-death risks, the practice immediately held a telehealth visit to straighten out his medication and set up a plan going forward.  
 
Her actions almost certainly saved another costly ER visit. But she also may have saved this patient’s life. His wife thanked Kristina for advocating on their behalf.

Filling in the gaps of our healthcare system can have life-changing results.  

Out of state, without a doctor, and in trouble.

A patient in Arizona was in and out of the emergency department nearly every weekend. Now, he says the ER is the furthest thing from his mind.   

There were issues with a catheter and a history of psychiatric trouble. But ultimately, it was the patient's anxiety about things beyond his control — aging, and even death — that spurred him to call for an ambulance so frequently.   

Amanda Edwards, RN, began working with the patient as part of Wellvana’s High-Touch Care Management in November of 2022.   

After months of weekly check-ins, he called and said he felt like he was “on the ledge” and may need the ER. But Amanda reviewed his symptoms over the phone, calmly listening to his concerns. The catheter seemed fine. Pain was not a big issue. He just needed someone to reassure him. 
 
At the end of the call, he said he was glad to have Amanda because he felt bad going to the ER so often and making his doctor seem like she wasn’t doing her job.  Since that conversation, he hasn’t been back.    

“I know I can call you, and you will make me feel better just by talking to me,” he told Amanda. “You don’t make me feel like I’m crazy.”  

‘You don’t make me feel like I’m crazy.’

A cancer patient in Texas was discharged from the hospital but needed to go to a skilled nursing facility. Fainting spells and memory lapses aren’t safe for someone who lives alone.  

🐕 But he wasn’t going to leave his dog again, even if it killed him.  

The patient’s wife died recently. He didn’t have anyone  to care for his pup, who was one of his only friends at this point.  

When Wellvana care coordinator Diana Mesa, MA, called as part of routine hospital discharge management, the patient declined to go to the nursing facility, even though he couldn’t recall the last time he ate a meal. He hadn’t picked up medication because he had no way to go get it.  

Diana knew he was not OK. It was time to think creatively to keep him healthy. 

So she called his pharmacy to help get his medication delivered to him. She set him up with Meals on Wheels while she worked on the dog problem. 

🐾 She found a local pet fostering program. When she called and relayed the situation, they waived the charge. 

With barriers removed, the patient accepted the care he needed to avoid hospitalization. He also now had another person to count on when he needed help. 

Modern healthcare can’t just rely on high-tech solutions. It also demands high-touch service. 

He refused to leave his dog, even if it killed him.  

👩‍⚕️RN or PI?🕵️‍♀️ 
 
After two ER visits for high blood pressure and two follow-up cardiology appointments, a patient in Arizona was still dealing with dangerous spells of high blood pressure. Wellvana Care Manager Amy Fairchild knew a third visit was likely not far away. 
 
She talked to the patient about her hypertension medication. The discussion revealed that the last time her prescription was refilled, the dosage was cut in half — a rare pharmacy mistake. 
 
No doctor had ordered the decrease. And they hadn’t caught it during follow-up visits. 
 
The patient was so thankful that the mystery was solved with a simple and reassuring explanation. “Sometimes, I feel like a private investigator in my role,” Amy told her. “When something is wrong with our patient, we take the time to make extra phone calls and go through everything to get to the bottom of it.” 
 
One ER visit — or potentially much worse — avoided. Another win for patients and for value-based care.

She thanked Amy, her private investigator

Her heart was beating too fast, but her blood pressure was low. Now she had a migraine. Given this patient’s tight schedule, she ended up driving to an ER in Arizona for answers. She left with none.   

When Care Coordinator Myanna Jury called the next day as part of Wellvana’s routine discharge management service, the patient resisted going to see her primary care doctor, mostly because of the same scheduling conflicts. It had to be during a narrow time window, and there were no appointments.   

But Myanna knew the combination of symptoms could put the patient at risk of shock or be a sign of something more serious. Without medical attention, she likely would be back in a hospital before long. Myanna made a few more calls and, working with the patient’s physician, found a way to squeeze her in.    

During the visit, the patient was also able to address several other health concerns that similarly had been unaddressed due to her busy schedule. She left with follow-up appointments and new motivation. On their next call, she thanked Myanna for empowering her to take better care of herself. Seeing a primary care doctor is often the best place to start. 

She left with follow-up appointments and new motivation. 

A patient in Arizona was discharged from the hospital, creating a critical moment for any health journey. This is why Wellvana calls to make sure patients see their primary care physician as soon as possible.  

This patient wasn’t interested.  

At first, he told Care Coordinator Michelle Wadley, LPN, he didn’t have transportation. Michelle offered to find him a ride, but he declined. 

On later calls, he blamed his memory. Eventually, he declared he was done with doctors.  

Michelle realized her patient was in a dark place, ready to give up on life after the death of his wife.  

Michelle eventually convinced this patient he owed it to himself — and his wife — to reconnect with his PCP.

A Tennessee patient's A/C went out in the spring. Even then, her indoor temps were hitting 80. Now it was June.   

Care Manager Beth Ann Ridings, RN, suggested driving somewhere to cool off on hot days. But this patient, trying to manage diabetes and renal failure, also didn’t have a car available. Social determinants were stacking up against her.  

Looking for a creative solution to avoid heat-related illness, Beth contacted local HVAC companies, but none could help. As a last resort, she reached out to a large local church to see if someone might step in. 

It took a few weeks, but by the end of June, church members installed a new A/C unit — all thanks to Beth’s persistence.      

Social determinants were stacking up against her.

At doctor appointments, a diabetic patient always seemed to forget to mention the regular trouble she had controlling her blood sugar.  

Her glucose was especially unpredictable after her monthly chemotherapy and steroid treatments. As a result, she was a regular at the local ER to get help with intense nausea.  

Then she started working with the Care Management team at Wellvana. During regular calls, Ashley Holyko, RN, listened to the patient’s concerns and directed her to try the doctor’s on-call line next time her glucose shot up.  

In short order, they worked out an insulin protocol that she now uses after each chemo treatment.  

Better health at considerably lower cost.

A patient in New Mexico was feeling dizzy and nauseous. She went to the hospital to pick up her spouse, who was being released after a bout with pneumonia. 

She decided to get checked out in the ER and left with no answers.

Since Wellvana follows up with patients within 48 hours of discharge, Care Manager Christal Santana, RN, called. The patient said she was still dizzy and nauseous. And now she was coughing up thick, green phlegm.   

Christal got her in to see her PCP within hours.  

It was pneumonia.  

She was prescribed steroids and antibiotics and told to go to the hospital if her symptoms didn’t improve.  

A timely primary care appointment can make all the difference. 


The patient said she was still dizzy and nauseous.

Beth Ann Ridings, RN, called for her weekly check-in. The patient explained how it was all falling apart — not just her blood sugar. 

The car A/C went out, TV on the fritz, and it was taking an outsized toll. These were headaches her husband would have handled. But he was gone now. 

She needed to see her PCP but didn’t want to go in a hot car. Even when her doctor offered to come to her, she refused. She said no to counseling. She wanted space.

But she'd talk to Beth. 

With permission, Beth involved a nephew. He helped his aunt see the importance of managing her glucose levels. 

Her numbers are much improved.

Our patients have more on their plates than what appears on their EMR.

She wanted space. But she'd talk to Beth.

A patient with dementia and her husband were hospitalized in New Mexico with COVID. She was sent home before he was, and that left caregiving duties to their son who was overwhelmed with bathing, dressing, feeding.  

After hearing the challenge from the son, Care Coordinator Myanna Jury contacted the PCP to request a home health referral.   

The patient now receives physical and speech therapy along with bathing twice a week. Myanna also linked the family with Meals on Wheels so when the spouse came home, he was able to focus more on his recovery instead of caretaking duties.  

Both have avoided another hospitalization. 

Sometimes care management requires watching out for the caregiver. 

That left caregiving to their son who was overwhelmed. 

A patient in Arizona needed two refills and notified her PCP. The busy office took a few days to call in the scripts. And delivery from the mail-order pharmacy takes up to two weeks.  

At this point, the patient was totally out.  

The PCP tried to help, calling in a two-week supply to a local pharmacy. But insurance wouldn't cover because of the other order, and the patient couldn’t pay full price. 

Enter Wellvana's Emily Buzhardt, RN, determined to untangle the mess. She hit the phones. It took three hours on the line jumping between the local pharmacy, mail-order pharmacy and health plan, but the patient was able to pick up the prescription in-person without missing a dose.

The patient was totally out of medication.

When a patient couldn’t reach his doctor, he called Care Manager Amy Fairchild, RN, and described concerning and escalating cardiac symptoms. She told him he needed to go to the ER.  

He called back days later to say thank you for saving his life, because he ended up needing quadruple bypass surgery. 

Aside from offering data and tech platforms to help primary care providers deliver life-changing healthcare, Wellvana literally extends their practices with care management to improve the lives of their patients. 

It’s not all about saving patients from unnecessary trips to the ER. Sometimes the hospital is exactly where a patient needs to be. 

He called back days later to say thanks for saving his life.

Care Notes

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Trinsic Clinically Integrated Network

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Care Notes

Care Notes

After days without insulin.

Taking charge after discharge.

Out of state, without a doctor, and in trouble.

‘You don’t make me feel like I’m crazy.’

He refused to leave his dog, even if it killed him.

She thanked Amy, her private investigator

She left with follow-up appointments and new motivation.

He was ready to give up on life.

Social determinants were stacking up against her.

She showed up regularly at the ER.

The patient said she was still dizzy and nauseous.

She wanted space. But she'd talk to Beth.

That left caregiving to their son who was overwhelmed.

The patient was totally out of medication.

He called back days later to say thanks for saving his life.

This is the way medicine is meant to be.

This is the way medicine is meant to be.