Health Home Care Manager Makes a Difference

The first sign that something wasn’t quite right was the falling down. “I was literally collapsing and I didn’t know why,” said Roger.

Over the course of the next eight years his health began to worsen. Roger didn’t notice how bad things were until one day all he could manage was to get up, scrounge for something to eat, and go back to bed.

“It was a dark situation. I was struggling in every way,” said Roger. “I was falling down often and I had a lot of problems that I didn’t understand – blurry vision, numbness in my leg, continuous falling, and suffering from back pain from a previous injury. I was struggling with basic needs such as getting food and doing laundry.”

A lifeline arrived in a letter Roger received from Ashley Arruda, a care manager from Behavioral Health Services North, a partner agency of AHI Health Home. AHI Health Home serves high-need populations by working with care managers who offer whole-person care, including physical and behavioral health care services.

“Health Homes serve the most vulnerable Medicaid beneficiaries by connecting people to extra non-medical supports such as transportation and housing,” said Annette Parisi, Health Home manager.

“I try to do things on my own. I’m a guy. But I was hurting myself and making things worse,” said Roger. “When I got the letter, it seemed like Health Home Care Management could help. I was very tired and frustrated and knew I needed help, so I called.”

“Ashley put me in touch with the right people. She got me a ramp to help prevent falls. Then I had an injection in my shoulder with a bad needle and I got a terrible infection and needed surgery. Ashley went with me to the surgery. Then she connected me to a new doctor, primary care physician Julie Steele-Goodwin, RPA-C, who has also been wonderful.”

One day Roger felt awful. His numbness and pain were worse. He told Ashley about his symptoms, but didn’t listen to her advice to go to the hospital. “Ashley showed up at my house and made me go to the hospital,” said Roger.

“She saved my life. I was just going to go to sleep. I didn’t know that my heartrate was dangerously low.” The hospital ran some tests and discovered that he had suffered a stroke. They also diagnosed Roger with MS. “Receiving help right away was critical in treating the stroke. The MS diagnosis was a surprise. I’d been struggling with all the symptoms for years and had no idea what was wrong.”

Working with a Care Manager

“I’m doing so much better. Ashley fills out paperwork and arranges for things I wouldn’t have known were available to help me,” said Roger. Home health aides now support Roger’s day-to-day living.

“I have help with so many things – meals, laundry, cleaning, and household chores. And I’m not falling and hurting myself,” said Roger. “I get fresh air, I’m happier and on the road to better health.”

What would you tell others about Health Home?

“I don’t like to admit that I need help,” said Roger. “I think that’s pretty common. I would tell others there are good people out there willing to help you. They’re very caring and they know what to do.”

A Heartfelt Thank You

Roger wrote a note of thanks to Ashley that summed up his feelings.

“Your kindness, caring work, knowledge of everything has made so many different, difficult challenges, concerns in my life that much easier to navigate. At times you have made the unbearable down right bearable. You’ve made it possible for me to keep my independence, have improved my quality of life in so many different ways, and have lessened my despair by either steering me to the right people that have helped me or have just given me your time. You have helped me at times by just listening to my concerns, my difficulties or just by showing me a smile with hope behind it. Thank You very much for all that you have done, do Ashley.

Learn More about Health Home

The AHI Health Home covers seven large rural counties in their entirety (Clinton, Essex, Franklin, Hamilton, St. Lawrence, Warren, and Washington), and parts of one county (Saratoga). Care Management agencies are spread across the region. AHI Health Home partners provide care management to enrollees/clients. These care management agencies are assigned clients based on capacity, geography, and specialty area.

AHI Health Home provides enhanced coordination of medical and behavioral health care by linking community and social supports with health care for high-risk Medicaid members with:

  • HIV/AIDS; or
  • a serious persistent mental illness; or
  • two or more other chronic conditions (e.g., mental health condition, substance use disorder, asthma, diabetes, heart disease, BMI greater than 25, or other chronic conditions).

Additionally, any of the following risk factors must be a component of the individual’s situation. These factors include, but are not limited to:

  • Homelessness or risk of homelessness;
  • Lack of social/family supports;
  • Deficits in activities of daily living;
  • Non-adherence to treatments;
  • Learning or cognitive issues.

“Health Homes have the potential to improve the overall health and quality of life of the people in our region,” said Parisi.

Visit AHI Health Home for more information.

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