Mr. T was diabetic, engaged in hoarding behavior and prone to hospitalizations before enrolling in our program. Through a gradual trust-building process, his nurse care manager was able to clear away the clutter in his apartment and create a path to the bathroom. More importantly, she learned that Mr. T bought all of his food at a nearby bodega. Given the importance of diet in managing diabetes, she brought a nutritionist to meet with Mr. T and the bodega owner and staff to discuss what he should eat and what he should avoid. With the help of his care team and bodega staff, Mr. T was not hospitalized for the next five years.

— RiverSpring

Until her sister’s death, Mrs. B lived with her sister in a railroad-style apartment. Now Mrs. B, who has severe Alzheimer’s disease, spends her days walking the length of her narrow apartment in search of her sister. Her home care aide felt she had to walk the halls with Mrs. B to keep her safe, but this made it difficult for her to care for Mrs. B’s other needs, including cooking and cleaning. After a nighttime fall, a staff visit revealed Mrs. B was often awakened by noise from the downstairs 24-hour deli. Staff bought a baby monitor so the aide could do her chores and monitor Mrs. B’s walks. A white noise machine made it possible for Mrs. B to sleep through the night, avoiding further falls. Our patient-centered care management yielded effective, low-cost solutions to issues that were otherwise likely to result in institutionalization.

— RiverSpring

Mrs. Q lived with her middle-aged daughter and required home health aide services. Yet aides were let go or left after just days. Our nurse care manager recognized that the issue was the constant, often-offensive criticism that the mother and daughter directed at the aides. Recognizing the danger to the mother without home care, one of our care management specialists with expertise in managing people and a background as a yoga instructor visited. While there, the specialist suggested some breathing exercises and light yoga. These exercises opened up communication pathways and the daughter agreed to modify her approach. Our specialist visited monthly and gradually coached both Mrs. Q and her daughter to correct their behavior. Following these interventions and coaching, home health aide turnover and Mrs. Q’s daily phone calls to complain about her aides stopped.

— RiverSpring

Nearly 20 years ago, Jonathan was the innocent victim of a drive-by shooting. In an instant, the 29-year-old went from being an independent, fully employed father who loved playing catch with his 8-year-old son to a quadriplegic who was completely dependent on others for his daily needs. After being discharged from rehab, Jonathan was determined not to let his condition defeat him. For the next 18 years, his caregiver, Mona, dedicated herself to ensuring that Jonathan received the care and support necessary for him to remain safely at home, including 24-hour support. Additionally, Mona coordinated with Jonathan’s physicians to ensure that his prescriptions were filled and that he received necessary care. Over time, Mona began to think of Jonathan as her son — and the feeling was mutual. “Without HomeFirst, I don’t know where I’d be,” Jonathan said. “I’d probably be dead.”

— Elderplan/HomeFirst

After being hospitalized for schizophrenia and methadone, 67-year-old Lauren lost her apartment. After her release, Lauren’s MLTC care team tracked her down and worked with her family and law enforcement to get her off the streets. After 200 nursing homes refused to accept her, Lauren moved into her brother’s apartment. Her care team assigned her a skilled nurse and personal care worker and gradually increased their hours. Lauren is now doing well: She is stable, back on her medication and no longer hearing voices. “You have no idea how relieved the whole team was to have achieved such a positive outcome for a member that was so at-risk of being lost,” said a caregiver.

— Elderplan/HomeFirst

Daily MLTC care managers perform for patients what no one else does. Emily needed the cast on her foot checked and her plan provided for regular visits. Her nurse care manager arrived to find Emily’s electricity disconnected and no food in the house. She promptly returned with batteries, food, water, lamp, flashlight and power banks and emphasized that Emily should call if she developed any increase in pain or experienced any new issues. Our skilled caregiver also made sure the power was restored, illustrating not only the holistic approach our staff embraces to keep patients healthy and independent, but also serving as an example of the critical importance managed long term care plays in ensuring our patients do not fall through the cracks during emergent situations.

— RiverSpring