CountyCare Member Story

Care Coordination Team At CountyCare Pulls Family Out Of The Cracks, Renewing Hope For A Better Life

It’s so easy to fall through the cracks when it comes to navigating the healthcare system. Patients oftentimes find themselves having to be their own advocates, but many don’t even know where to begin, or the resources available to them.

This is what happened to one CountyCare member and his family, before joining the Medicaid Managed Care  Organization.

Sixty-one-year-old Norbert joined CountyCare in early 2021. Prior to, he had been a part of the Medicaid Fee-for-Service Program, where he and his family fell through the cracks.

An initial care coordination assessment in February 2021 uncovered that John had not received medical attention since 2014 when he was admitted to the hospital. After being discharged, he never received any follow up medical attention.

John was born with developmental delays and substantial functional limitations, including aphasia and hearing problems. He lives with his two older sisters, an older brother, and their sick elderly mother. One of his sisters and his brother also have intellectual disabilities. Their father passed away from cancer in 1995, leaving his mother to raise them on her own, until she too fell ill. His mother is now in hospice and is cared for by one of his sisters in the Chicago home they all live in together, the only home Norbert has lived in since birth.

John was at a very high risk of being institutionalized without CountyCare’s intervention. Had it not been for the work of the care coordination team, John would most likely have ended up in a nursing home indefinitely.

John’s care coordinator facilitated:

• Educating the family on what resources were available to them and John.
• Arranging for doctors and a medical team to visit John at home to assess his medical needs and medication regimen, as well as draw necessary labs.
• Securing occupational and speech therapy for John to assist with his aphasia and limited functional capabilities.
• Coordinating homemaker assistance, which now visits John five days per week.

John and his family faced a myriad of issues that should have been mitigated by a variety of medical professionals they encountered throughout their healthcare journey, but instead, remained unaddressed until CountyCare team members stepped in and took the time to walk into John’s home and assess and address the various needs of the

member and his family.

This removed a huge burden of stress from one of John’s sisters, who is a caretaker for John, their mother in hospice, and John’s two other siblings, who also have intellectual disabilities. “We felt alone, like the entire world forgot about us,” his sister said. “We gave up.”

John’s care coordinator said her mission with the family, and with all of her members, is to “bring hope, hope and one more time, hope.” And in just six short months, John and his family experienced firsthand what this truly means. In this short time, thanks to the coordination of a variety of inventions, John is now able to prepare and eat his own meals

and snacks, take walks around the block with his sister and enjoy time in the backyard with his family, all notable wins that have given this family hope again.

“Only working together as a team - care coordination team, medical team, home health team - all have to work together to make a difference and bring results,’ said Bozena Miltko, John’s care coordinator. “Even small changes are big changes for members.”

In most instances like this, patients like John would be institutionalized for life, due to caretaker burnout, neglect or hospitalization that leads to continued health decline. Many of those patients get lost within the Fee-for-Service program, which compartmentalizes members and their care and places the burden of navigating care and needs on them, rather than seeing them as a whole person and coordinating care to align with this perspective.

With the intervention of MCO, members benefit from the care coordination team providing better access to medical professionals, helping facilitate care and aiding in obtaining necessary resources like they did for John and his family.

“Every care manager that does a good job is going to run into cases like this,” said Debra Brophy, Director of Integrated Care Management and Behavioral Health at Cook County Health. “This is the norm, this is what we do. (But) you really want to get that great outcome, and that takes time, but thankfully in this case, in six months, this was a great, short

turnaround for this member to see a great outcome.”

* Names and identifying details have been changed to protect anonymity