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How coordinated care gives patients the freedom to stay at home

BY   July 27, 2015 at 10:26 AM EDT

Editor’s note: As America’s population ages, more families will be faced with rising health care needs. As we reported in November, nearly 79 percent of adults who need long-term care live at home or in community settings, not in an institution. And in January, Medicare started paying primary care doctors a monthly fee to better coordinate care for the most vulnerable seniors — those with multiple chronic illnesses — even if they don’t have a face-to-face exam. The goal is to help patients stay healthier between doctor visits, and avoid pricey hospitals and nursing homes.

So how does coordinated caregiving work? Meet three older Americans with chronic illnesses who are benefitting from coordinated caregivers in their homes.

Betty Valdez has chronic lung disease, known as COPD, high blood pressure, kidney disease, arthritis and diabetes. Remembering when to take her 20-plus medications is difficult. Getting up from a chair is a significant obstacle, making any regular exercise unlikely. With a primary care provider and help at home, maintaining her current health would be a challenge. Without them, the 65-year-old Valdez spent a lot of time in the emergency room.

At least she did until about a year ago. After complaining of problems breathing, Valdez visited the ER at a Denver hospital. While there she agreed to enter a new program called Bridges to Care, run by Metro Community Provider Network, a community health center outside Denver. “We usually come into contact with patients who are dealing with one or more acute issues. That’s why they end up on our radar,” said Linda Skelley, a clinical care coordinator in the program. “Typically, there are also multiple underlying issues or preventative services they might not have been receiving.” The main goal of the program is to reduce ER visits for patients like Valdez, so-called high utilizers, by conducting an initial assessment and organizing resources to fill the major gaps.

In the ten months Valdez has been in the program, she has seen a primary care provider who performs regular preventative screenings and maintenance tests for existing conditions. She also sees a nurse several times a week at home for help with taking medications and to check vital signs. Skelley works with the rest of Valdez’ healthcare team to identify areas of need. When Valdez’ pulmonologist recommended a lift chair to ease problems standing up, Skelley got the chair approved and paid for through Medicaid. When Valdez’ primary care provider suggested an automatic pill dispenser to simplify her daily medication routine, Skelley again made sure it was approved and paid for.

The Bridges to Care approach has been effective. When she began the program, Valdez was not only visiting the ER, she was often admitted to the hospital. After 3 admissions in the first 3 months of the program, Valdez has been once in the last 3 months. She has seen the difference. “Since all the medical care that I got here, my mobility is stronger, I got so much better. It gives you more of a reason to want to keep going and live longer.”


Eighty-seven-year-old Eileen Daniels lives by herself in New York City. She prepares her own meals and pays strict attention to even the smallest aches and pains, scheduling doctor visits when necessary. Daniels is remarkably healthy and motivated to stay that way.

“She’s in great shape. She takes responsibility for her medication, for her care,” says Michele Walcott, who has coordinated Daniels’ care for four years, helping her manage her hypertension and sporadic mobility issues. People with more serious chronic conditions have significantly more complex daily routines and a much greater need for outside help. For a comparatively healthy patient like Daniels, that means helping to organize (and reminding her to take) prescriptions, setting up a regular home health care aid and referring specialists according to need.

As she ages and the severity and number of health issues increases, Daniels will likely depend more on Walcott to keep her healthy at home.


If Burt Kramer wants to keep living at home, he knows he needs help. “When you’re elderly, you have to have people to help you.” Even a relatively healthy 75 year old may have problems with grocery shopping or household tasks. Kramer has to manage two serious chronic conditions: congenital heart disease and diabetes. He takes 15 different medications a day — some more than once.

Christine Spates, a care coordinator at Visiting Nurse Service of New York (VNSNY), checks in with Mr. Kramer regularly to make sure he remembers to take his medications, eats right and reports any indications of heart problems. Kramer also has a home health aide who helps with personal care (bathing and fixing meals). “He needs another set of eyes, another set of ears to make sure he is adhering to all the instructions as related to his illnesses, so that he can remain healthy at home,” Spates says.

So far it’s worked. Kramer hasn’t been hospitalized in more than a year while under VNSNY’s care.

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