Humana Member Story

From Crisis To Community

History

PM is a 35yr old woman who has been enrolled for approximately 8 months. She has a medical and behavioral health history of Alcohol Abuse, Bipolar Disorder, with psychotic features, Conduct Disorder, Asthma, Tobacco use, Unspecified Abnormalities of gait/mobility and Weakness, history of domestic abuse. P.M. was admitted to nursing home to a behavioral health crisis that led to a motor vehicle accident. P. M’s POA/mother reported she attempted to drive alone to California while experiencing auditory hallucinations causing a one car accident. She sustained injuries to her leg and back causing weakness and unsteady gait.

She was brought back to Chicago to receive care including physical and occupational therapy to regain mobility and strength and subsequently her and her supports decided that long term care was the best option for care due to member needing assistance with both physical and behavioral health assistance. Her mother who was also her POA over Healthcare admitted her to Long Term care so she could be stabilized on her medications as she received much needed therapies.

Barriers

P.M. verbalized that she was ready and willing to return into the community but needed some considerable support from her formal and informal supports. P.M. struggled with remaining adherent to her medications when residing in the community. P.M. has a history of being in a domestically abusive relationship which caused a decline in her mental health. She was distant with her family for an extended period until she was admitted to long term care. For P.M. to have a smooth transition into the community she needed to be connected to behavioral health care provider to be monitored and stabilized on her medications. She also needed additional supports with Activities of Daily living and instrumental activities of daily living due to her mobility issues and weakness. P. M. Also verbalized some difficulty navigating public transportation and reported that she is forgetful and needed some assistance with getting to appointments.

Interventions

P.M enrolled into the community Transitions Initiative Program in January 2024. Her LTSS Care coordinator worked with P.M and her supports to ensure that her transition into the community was smooth and that member had the appropriate services in place. CC referred her for a Person’s with Disability waiver through the Department of Rehabilitative services (DRS). P.M. has strong support system through her mother who also assisted her with removing herself from a domestic violent situation. The CC also worked with P.M. and her mother to secure a psychiatrist within the community as well as a PCP. She was also assessed for outpatient therapy services and Community Support Team services through Thresholds.



Outcome

P.M transitioned into the community in early April 2024. She was approved for waiver services later that month. She is now receiving outpatient therapy services and attends scheduled psychiatrist appointments through Thresholds. P.M.’s sister applied to become her Personal Assistant through the Person’s with Disability waiver and will be able to provide her with assistance with ADL’s and IADL’s within the home.

She is now learning to live independently in the community and learning how to make small meals and grocery shop. She can communicate her feelings and understand the importance of adherence to her medications. She has a behavioral health crisis plan which she has worked on with her outpatient therapist to ensure she is able to respond appropriately during a crisis. P.M has remained stable since her discharge into the community and continues to receive daily visits from her mother who is her natural support.