Roger had been cycling in and out of the hospital due to his many health conditions. He struggles with consistently following up with primary care physicians for his end-stage renal disease, diabetes, asthma, coronary artery disease, hypoxemia and cirrhosis. So much so that he would be discharged from several practices. Roger also had difficulties completing his dialysis treatment. When he would go to the dialysis center, he would complain of chest pain and be transferred to the emergency room for evaluation. Once he was admitted for observation and receive his hemodialysis, he would sign out against medical advisement to return home to care for his dogs—his only companions in life.
Roger was eventually referred to a Health Home after coming into the emergency room. He enrolled as a member of St. Mary’s Healthcare Health Home. At his initial intake at his home, he met his Health Home Care Manager, Trish. Trish started by engaging several agencies to help Roger with both his medical and personal care needs. Through Adult Protective Services, Roger was given 60 hours a week of personal care in his home. His Care Manager also negotiated with Roger’s former physician to re-accept him as a patient. As part of the arrangement, Trish would ensure that Roger would attend all his appointments and follow up with specialty providers and lab work appointments. Trish worked with Roger to develop a plan to get him through his hemodialysis and ultimately improve his health. Since enrolling in St. Mary’s Healthcare Health Home, Roger went from visiting the emergency room 118 times in 2016 to 13 visits the following year. Roger is now living a happy and healthier life with his two dogs.