Humana Member Story

A Path To Independence

History

J.A was initially unable to be contacted until one of our nurses, Jennifer, was able to reach him following a hospital admission. J.A. is from Puerto Rico and speaks Spanish. Further challenges for J.A. are low literacy as he let us know that he never learned to read or write. J.A. is difficult to understand on the phone as he is usually very tired from hemodialysis or from completing his daily activities. He has bilateral below-the-knee amputations, anxiety, depression, diabetes, end-stage renal disease, dialysis, liver cirrhosis, possible liver Cancer, pacemaker for arrhythmia, as well as being an oxygen-dependent asthmatic. J.A. also lived with his sister and wanted to find a place of his own as they had not been getting along.

Barrier

Poor historian, low literacy, mobility difficulties, transportation, knowledge deficit in medications and medical conditions, lack of knowledge regarding his plan benefits and resources. He also fatigues easily which can make it difficult to address identified gaps.

Interventions

After the first contact with the J.A., Jennifer began working on his numerous needs. She had post-discharge meals sent and provided verbal and written dietary information to him. She continued working with the J.A. over the next several weeks, speaking to him often which identified further needs and worked to close those gaps. One of the big priority interventions was referring to our social worker for services for in-home assistance and housing needs. J.A. prioritized seeking his own housing at that time and also wanted to defer his LTSS application. Over the next several months, Jennifer and the social workers worked to close his numerous health gaps by placing referrals, making phone calls, assisting in scheduling appointments, and providing written information. Due to J.A.s barriers, the team completed numerous calls per month as well as coordination with the team and other providers to meet his needs. At times, J.A. would defer an intervention and opt to wait until his sister could be present or would request a callback. Sometimes J.A. would be tired from completing his ADLS or attending dialysis and would not want to engage on the phone. To overcome these barriers, the team persistently followed up with J.A. to support his needs. We also transitioned J. A. to a Spanish-speaking social worker and Spanish-speaking Care Coordinator.

Outcome

Since our initial contact with J.A. several months ago, he has successfully moved into his own apartment and has had an in-person visit which showed a clean, appropriate, safe environment. He also has received portable oxygen, a blood pressure monitor, and a blood glucose monitor. We have ensured that he has transportation to all appointments and regularly scheduled transportation to dialysis via MTM. We also assisted in successfully transitioning his prescriptions to Humana’s CenterWell pharmacy so that he could receive his medications through the mail.



On his most recent contact in May, he decided that now is the right time to pursue applying for LTSS services and has begun that application process and is awaiting approval. Our team continues to support J.A. until he has these much-needed services in place. This story highlights the numerous challenges he faced and the amazing teamwork that went into overcoming his many barriers and closing these gaps.