Humana Member Story

Humana IL LTSS Community Transitions

(Member Initials): H. D.

(IL MMAI Waiver and LTC Program)    IL MMAI LTC

History

H.D is a 75-year-old AA male who was residing in a Long-Term Care Facility (LTC). He was initially admitted due to a motor vehicle accident causing him to have a fractured femur. H.D was living out in the community; his accident caused significant issues for his ability to care for himself independently and which caused him to go into custodial. He required total assistance with all ADL’s and IADL’s. H.D began physical therapy within the facility and regain some mobility and was able to ambulate with a rolling walker. He started to express to this care coordinator that he wants to return to the community to live independently once again. He wanted his own apartment but did not know how to begin the process of transitioning out of a facility.

Barriers

H.D met with the IL LTSS Community Transitions Care coordinator who assessed him for appropriateness for transition into the community and discussed some of the barriers that may delay the process such as housing limitations and ensuring he had the appropriate level of support to make it a safe transition into the community. 

H.D reported he had limited support and that he has one relative that he communicates with and no other supports. He reports he was staying with family and friends prior to going into Long Term care and would need assistance with finding accessible housing. He expressed his desire to live independently but acknowledged that he would benefit from medication management and assistance with meals.

Interventions

Member became a part of the Colbert Program to transition back into the community. Member was educated on the benefits that the program offers. Member stated that this program was heaven sent and was very grateful for being a part of the program. CC and member collaborated to research different facilities to see which one would suit the member’s needs. Member was provided health education post discharge. 

CC referred member for the Supportive Living Program waiver and coordinated with a Supportive Living Facility (SLF) and H.D. to ensure that he would be able to receive the care that he needed but also have autonomy to come and go as he wants.

Cc worked with the Long-Term Care facility to obtain documents needed for member’s transition. Although H.D has improved from his accident he continues to need assistance. Care Coordinator discussed the Supportive Living Program which is a waiver program that allows members to live independently with some minimal support from professionals. He would have 24hour supervision from medical and social service staff and would have access to medication management as well as meals.

Outcome

H.D was able to successfully transition to Green Oaks of Park Forest Supportive Living Facility in September. The Supportive Living Facility will be able to support member with medication management as well as providing meals to member.  He now has his own studio apartment which was furnished with a bed and a recliner seat with funds from the Community Transitions Initiatives program.  He will be seen by a nurse daily and will receive medication reminders daily. H.D  can independently check his own blood pressure and has a blood pressure cuff in his apartment and will be seen by a PCP monthly.

H.D can independently request transportation with Pace and has access to using MTM as needed. There will be staff at the SLF that will be there to assist with the ADL and IADL needs.

CC followed up with member to ensure he is transitioning well; and he reported he is very happy and grateful to be in his own apartment. H.D reported the staff at the SLF are very helpful and he is enjoying the meals that are provided daily. He reported that he will be participating in the activities within the facility and is happy to be in an environment where he is able to thrive. H.D reported that he is enjoying meeting new people and couldn’t be more grateful to be living independently.