Herald is a 62-year old previously diagnosed with diabetes, epilepsy, dementia, depression and mild intellectual disability (MID). He was frequently having seizures and feeling depressed or disoriented since he was unable to adhere to his medication regimen and follow up with his providers. Additionally, Herald was often in the emergency room for his safety and well-being.
On top of his poor health, Herald had a very unfortunate living situation. He was living in a shack with no running water, electricity and heat in central New York. He was consuming uncooked meat and large quantities of alcohol and ignoring his personal hygiene. There were also limited transportation options near his home which inhibited his ability to access food. Herald’s home would later be condemned, forcing him to live on the streets. Sadly, Herald doesn’t have very many people to which he could turn to for support. His only family members are his 85-year old mother, his sister, who also suffers from severe dementia, and his brother, who struggles with drug addiction.
During one of his visits to the emergency room, Herald was referred to Central New York Health Home Network (CNYHHN), where he met his Health Home Care Manager—Carl. Carl started by arranging temporary placement in a shelter, so Herald was able to get cooked food, a shower, a bed and clean clothes. His Care Manager worked with Herald and his providers to get the appropriate medications to better control his diabetes and seizures. Carl would arrange transportation for Herald’s visits to the doctor and coordinate with Herald’s visiting nurses. Carl would take the time to take Herald to the grocery store and teach him basics on how to purchase healthy foods. Carl worked with the Social Security Administration to ensure that Herald’s benefits were never lost and coordinated with social service agencies to explore options to ensure that Herald was more financially stable. His Care Manager helped Herald apply for an assisted living facility in his hometown.
Since Herald started working with Carl, Herald has not used the emergency room in four months. He is now able to follow up with his provider appointments and take his medication. His diabetes and seizures are now under control. Herald is now sober and living a much healthier life. He also has developed a closer relationship with his sister, who lives in the same assisted living facility.