Editor’s note: This is the last part of an eight-part series that previously appeared in an abridged form in Becker’s Hospital Review. The example below illustrates the segmentation and care of one subpopulation; others have been shared in previous weeks.

Doris is a 63-year-old widow with heart failure, diabetes, and kidney dysfunction. She has a primary care physician who has been treating her diabetes, a cardiologist for the heart failure she developed two years ago, and a nephrologist because her kidneys are failing.

She has a long history of diabetes. In the past, Doris’ diabetes was not well controlled. She did not feel that she understood her diet or medications and at times, skipped her medications. Several times, Doris was discharged from the hospital only to be readmitted within a week or two when her diabetes got out of control or she developed another complication. She racked up significant medical expenses due to the hospitalizations and the many physicians involved in her care.

Now, her team of physicians from your health system has access to all of her medical records, and they are kept up-to-date with her current medications and recent lab tests. All of her physicians are on the same electronic health record, so they all have access to the same information in a timely way.

Doris’ daughter lives out of town. She worries about her mom, but is able to log into the medical record as a proxy and see all of her mother’s test results. She also can email her mother’s doctors with any questions.

Doris now participates in a care coordination program. She enjoys the classes about how to live with diabetes, the importance of her diet, and medications. She has a glucometer that measures her blood sugars and transmits the results electronically to her physician’s office. If her blood sugar is out of whack, she receives a phone call with instructions from her doctor or physician’s assistant. She hasn’t had to return to the hospital for her diabetes, and her daughter is very relieved.

Every other month, Doris visits the heart failure clinic, where a heart failure specialist and a team of professionals help make sure that her medications are adjusted properly. The electronic health record provides all of her caregivers with alerts about possible medication interactions and other information.

In between visits to the heart failure clinic, a nurse coordinator visits Doris at home to ensure that her questions are answered, her living situation is safe, she is taking her medications as prescribed, and she is keeping her appointments. Doris checks her weight and the nurse coordinator monitors her readings as they are transmitted electronically from Doris’ bathroom scale. She gets calls from the nurse to see how she is feeling and instructions from the heart failure clinic regarding any medication adjustment.

Doris is also attending cardiac rehabilitation. An exercise physiologist has worked with Doris to design an exercise program that is helping her feel stronger while not overly stressing her heart. The program has even helped her better control her diabetes.

While Doris’ daughter was in town visiting, the palliative care nurse and doctor visited to see if there was anything they could do to help with any shortness of breath or other symptoms. They discussed whether Doris would want dialysis if her kidneys stopped functioning. They also talked about what Doris would want if her condition deteriorated, she ended up in the hospital, and faced the possibility of CPR or a breathing machine.

Decisions agreed to meant that Doris’ daughter would not have to make the decision if Doris was unable to or her daughter could not be reached. Doris and her daughter were grateful and relieved to be having this discussion. And in the meantime, Doris feels better and stronger than she has in years.