Harry is 57-year old man living alone in an apartment in New York City. He has been diagnosed with end-stage renal disease, peripheral vascular disease, diabetes, hypertension, and chronic obstructive pulmonary disease (COPD). Additionally, Harry struggles with chronic pain and has a history of stroke, and prostate and thyroid cancer. Given his renal disease, Harry has been on dialysis for over 12 years. He has limited mobility and requires the use of a motorized wheelchair. In 2015, he visited the emergency room 137 times at approximately the same time of night, which physicians suspected to be anxiety-induced.
His frequent emergency room visits led to Harry being referred to a Health Home. He was specifically referred for his difficulty adhering to his medication regimen, abiding by doctors’ instructions to limit his liquid consumption, and refusing any additional support. To help Harry, John, his Health Home Care Manager, established a trusting and supportive relationship by providing him what he needed and supporting him at his appointments. John convened case conferences and coordinated the care he was receiving from multiple providers and health care systems.
As a result of working with John, Harry was connected to a managed long-term care (MLTC) plan that authorized longer stays at a dialysis center and pain management. His Care Manager, John, was also able to get Harry a shower chair which enabled him to be more independent in his self-care. Harry is now able to better manage his medication and even able to self-advocate for anti-anxiety medication. John continues to support Harry in managing his complex health needs.