Success Stories*

*These Success Stories are based on true cases; the names have been changed for the privacy of the patient. 

Gloria, a 64 year-old woman with a past medical history of asthma/COPD, diabetes and rheumatoid arthritis was referred to the Transitional Care Program for diabetes management.  


 One of the common tests conducted to monitor diabetes is a Hemoglobin A1c, which measures glucose in the blood over a 3 month period. In a person without diabetes, the average range is 4% to 5.9%.  When Gloria first came to the Transitional Care Program, her A1c level was 13.1. 


After 8 months of participation in the program, Gloria was able to lower her A1c to 6.0%.  This was achieved through frequent telephone (i.e. tele-management) calls to monitor compliance with the doctors recommendations and effective medication management.

Douglas, a 71 year old man, was referred to our Transitional Care Program after multiple ER visits and hospital admissions for uncontrolled COPD and Pneumonia.  His medical condition was complicated by congestive heart failure, hypertension, hypothyroidism, chronic pain from arthritis, and insulin-requiring diabetes caused by steroids needed to treat his lung disease.  He also had psychiatric conditions (Major Depression, Schizoaffective Disorder, and Explosive Personality Disorder), which had led to him being banned by other medical clinics, and even being placed in jail.  When he first came to our Transitional Care clinic, he was homeless.


One year after referral to our program, Douglas can manage his COPD with only two breathing treatments per day.  He no longer requires chronic pain medication, and his diabetes is controlled by diet alone.  He even has quit smoking, and has begun a regular exercise routine.  He has required hospitalization for his lung problems only once in the prior 6 months, which has led to a significant improvement in his life style.


We are proud of the progress that Douglas has made in the management of his chronic medical conditions through his partnership with the Intercede Health Transitional Care Program.

Judy had smoked cigarettes for most of her life, and as a result, had developed an advanced form of COPD.  She needed treatment with oxygen in order to allow her to do even the simplest of tasks.  Even with the extra oxygen, she was unable to walk much more than short distances, and had to use a wheelchair if she was going to go more than that.  She also had required multiple hospital admission to treat recurrent episodes of pneumonia and respiratory failure.

When she was referred to our Transitional Care program, Judy underwent extensive counselling and support, and was able to quit smoking, and to stay quit, for the first time in years.  As a result, her lungs began to improve and she no longer needed extra oxygen.  She now is walking without assistance, and her strength and endurance are growing.  Additionally, she does not need to take as much medication to treat the COPD as she had needed before, and this will decrease her future risk of complications like osteoporosis and bony fractures.

We are proud of Judy and of the way she has worked with our Transitional Care team to improve her health, both now and for the future.

Leo has COPD, but he finally quit smoking after effective and repetitive education, counseling, and support initiatives by our Transitional Care  Physician.  He is happy to report that he is now off  prednisone and oxygen. 

If you wish to enroll in the Transitional Care Program, please have your Primary Care Physician contact:

Andrea Spence, Enrollment Manager at 

832-476-3900  or 800-869-4094

Or click here to request an appointment

When we first met Della, a 71 year-old woman, she had diabetes that was so poorly controlled that she had developed a severe complication called diabetic gastroparesis.  This made the management of her other GI conditions (GERD and Irritable Bowel Syndrome) even more difficult.  She also had issues with chronic pain, depression, hypothyroidism, arthritis and osteoporosis.  Her GI symptoms were severe enough that she sought care through frequent trips to hospitals and ERs, which had led to multiple procedures being done, but without any benefit to her.  Additionally, her irregular eating habits caused by these conditions made her diabetes even more complicated to manage.  Her Hemoglobin A1c was abnormally elevated at 9.5%, which placed her at risk for even further diabetic complications.


After participating in the Transitional Care Program, she has been able to manage her diabetes more effectively, as evidenced by the reduction of her A1c down to 6.8%.  She no longer has to take medications to reduce stomach acid or to treat gastroparesis, and she has not required a hospital admission in more than two years.


We are proud of Della, and the success she has learned to achieve in the management of her chronic illnesses through partnership with the Intercede Health Transitional Care Program.

Jeremy, one of our younger patients, was referred to us for treatment of congestive heart failure, severe asthma, hypertension, and diabetes – all of these were made worse by his morbid obesity, as his weight was 350 lbs when first coming to our clinic.  He had required frequent hospital stays to treat flare ups of his heart and lung conditions.


Through adjustment of his medications as guided by our Transitional Care physician, Jeremy gained improvement in his lung function.  He also underwent regular counselling on diet and nutrition.  These all helped to prepare him for bariatric surgery to address his obesity.

After completion of successful surgery and also because of the ongoing work he has done with nutrition, Jeremy has lost 61 pounds so far.  His other medical conditions are improving as well, and he now needs 5 fewer medications than before to treat them.  His diabetes is completely controlled by diet and exercise alone.


We are proud of the hard work that Jeremy has done to change his life for the better, and we look forward to watching him continue to improve through his partnership with the Intercede Health Transitional Care Program.

Susan,  a 37 year old woman, was referred to our Transitional Care program for management of depression, chronic back pain, and hypertension.  Her depression was made worse by the death of a baby who had been born prematurely, and was so severe that it caused her not to be able to take care of the other 5 children that she had.  She often did not eat, reporting instead just to drink sodas.  Her back pain required multiple medications, and this provided only partial relief.  She came to our program after her Pain Management physician discharged her from his practice.  On her first appointment with us, she was so emotionally distraught that she felt she had to stop the discussions, and return at another time.


In addition to providing the support that Susan needed, our Transitional Care physician recommended that she start a medication to treat her depression.  She was asked to keep logs of her diet and exercise.  The multiple pain medications were slowly tapered as she improved.