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Teaching patients how to take better care of themselves at home

 Sharon Bearor "We support you, and we watch out for you."

Q&A with Sharon Bearor, RN, BSN, Chronic Care Specialist, Ibis Health Program 

For the roughly 4 in 10 Americans facing two or more complex chronic diseases, navigating the health care system can be overwhelming. With multiple doctor visits and medications to keep track of, patients may experience repeat visits to the emergency room, unplanned hospital stays, and missed days of work when they suffer symptom flare-ups or exacerbations.

 Sharon Bearor understands the challenges these patients and their families face because her only son was once one of them. Born with cystic fibrosis, her beloved Spencer survived — and thrived — for 38 years, at one point becoming one of the first patients in the country to successfully receive a living-donor double-lung transplant. As a single mom, and as a registered nurse, Bearor had to teach Spencer how to take ownership of his disease, training him from a young age to set up doctor’s appointments independently and communicate with pharmacists. “It helped me to understand empathy, understand chronic illness, understand fear and grief,” Bearor says.

Bearor brings that understanding and experience to her new role supporting members of the Ibis Health Program. The Ibis Health care team bridges the care gap between visits to medical providers, engaging patients in dynamic daily planning and goal setting that allows them to take better care of themselves at home. Senscio’s patented care management AI powers the system, monitoring patient vitals and care plan adherence, engaging the patient in self-management and symptom management, and alerting the care team when issues arise.

 Bearor has spent much of her 40-year nursing career working to improve quality of care for patients, training other medical providers in skills ranging from active listening to collaborative care and shared decision-making processes. Her resume includes roles with the Maine Health Exchange; as clinical coordinator for Mid Coast Hospital (Brunswick, ME), overseeing a 26-physician cross-specialty ambulatory care group; and most recently as a clinical educator and project coordinator for Maine’s HealthInfoNet.
Senior lady using ibis

As a chronic care specialist for Senscio’s Ibis Health program, what do you do?

 “My primary role is to evaluate the data that comes in from the tablets. The members enter in their vital signs and that data comes into our system. I look at it, and if there is a value that is out of sync — blood sugar that is too high, for example — I open the record, look at the patient’s data and critically evaluate it. I look at the big picture and then I make a decision: This looks OK or maybe we need to call the patient to check in. I also meet with each member in the beginning to review their medications, making sure they know what they are for and how to take them.”

 What does this look like on a day-to-day basis?

 “Well, for example, one of the things I dealt with this morning was a patient who had a very high blood pressure reading. The patient is at home, pulse is high, blood pressure is high, breathing test is a little low. The doctor would never know this because the patient is not sitting at the doctor’s office. I see it, so I call the patient and now she is going to call her doctor’s office to check in. And when I coach a member, ‘One of the things you need to do right now is call your doctor,’ I will also say, ‘And when you speak to them, let them know this and that.’ I prepare them for the appointment before they call. And I can also call a provider to give them my hands-on experience: ‘I’ve talked to this patient three times this week, and this is what I’ve observed.’ In this way, we are the eyes and ears for our members. We teach patients how to take better care of themselves and also how to communicate with their providers.”

How can this be helpful to providers?

“We are an extra set of eyes to look at data on your patients’ vital signs. And we are RNs who are trained in critical thinking and can determine signs that may require more attention from a provider. We prevent hospitalizations, which is always good, keeping our patients safe, healthy and feeling good. We get 60 minutes of live support per member per month to be able to take care of them, and that is a lot.”

How would you respond to a provider who says my patients will never do this?

“I would say hogwash! They are doing it. Our 80-year-olds are doing it. And we meet them where they are. Can you only do your pulse? Great, we’ll keep an eye on your pulse. And then we’ll teach you how to take your blood pressure. Our guidance and support are extraordinary in this company. The tablet is easy to use, with big icons for people who have sight issues, and we’ll walk you through it. And every month, you’ll get a call from a member advocate for a general check-in. They’ll ask questions about your health, but maybe also about the pets and how you are spending your time. This is so meaningful for patients’ state of mind, and their isolation, and helps us to know, hey they are out playing cribbage, they are doing well. They feel that someone cares. That’s on the hierarchy of needs, to be cared for and to feel loved.”

What else would you like providers and patients to know about the Ibis program?

“We don’t treat, and we’re not providers. We are a watchdog. We support you, and we watch out for you. Every patient I’ve talked to, they like the fact that someone is looking after them.”

To learn more about the Ibis Health Program by Senscio Systems please visit: