No access to a bathtub. No bed. A lost insurance card. Just three of the issues uncovered by a health coach intervention during the initial pilot phase of a pioneering collaboration between Partners in Care Foundation and the Los Angeles City Fire Department (LAFD) aimed at reducing non-emergency calls to 911.
Over the forthcoming months, we will focus on patient stories from the frontline of the intervention. Our aim is to explore some of the circumstances that cause people to become high utilizers of emergency services, and to share those learnings in an effort to identify best practices for caring for this often hard to reach population. The LAFD/Partners pilot will also be exploring new collaborations with health plans to connect patients with care managers to understand covered benefits and services. Partners’ coaches are teaching patients how to access and utilize health plan benefits, linking them to essential treatment services like primary care, specialists, and behavioral healthcare, to promote good health practices and deter 911 utilization. All patient names have been changed to protect identity.
Maria had called 911 so many times over a five month period that the team running the LA Fire Department Nurse Practitioner Response Unit (NPRU) knew her by name. But repeated call outs and trips to the emergency room had done nothing to alleviate the problems that Maria was experiencing, prompting the NPRU to refer Maria to Partners for a health coaching intervention.
When health coach Francisco Moreno visited Maria, it quickly became apparent that a major contributor to her distress was that she didn’t have a bed of her own. She’d been sleeping, poorly, in a bed she shares with her niece in the home her daughter rents – not an ideal situation for a woman who relies on a walker to get around, and is dealing with a host of serious health issues including asthma, arthritis, heart problems, gastrointestinal ulcers and anxiety. Francisco also discovered that even though Maria had health insurance, she didn’t understand how to properly use the benefit, and was struggling to make and keep appointments with her doctor, a difficulty exacerbated by the fact that she is a monolingual Spanish speaker. She also desperately needed assistive devices for bathing and using the bathroom.
While Maria, who is 68, wished to remain independent and not rely on her daughter, her health conditions increasingly meant that she was unable to fully care for herself. A thoughtful neighbor had been helping her, without reimbursement, working as an informal caregiver to assist Maria to shop and prepare food.
“She needed a lot of help understanding how to use her health insurance benefit and what services are available to help her,” explained Francisco, who is a fluent Spanish speaker. “My immediate thought was that she would be an ideal candidate for the Multi-Purpose Senior Services Program (MSSP), a federally funded program that helps low income seniors to remain independent, by providing assistive services that allow them to stay out of nursing homes.”
After the visit, Francisco contacted the staff at MSSP South, a site operated by Partners in Care, and was able to find an available slot for Maria. Sandy Bustamante, who was assigned as Maria’s MSSP care manager, visited her soon after. “The family’s sleeping situation was unsatisfactory for everyone, and both Maria and her niece were very happy at the prospect of having their own beds. It’s a small improvement, but a crucial step towards helping stabilize Maria’s situation.”
A short time afterwards, through funding from the MSSP program, Sandy purchased a bed, a standing fan and a range of incontinence supplies for Maria. She also provided her with a pill box, and showed Maria how to use it to organize and manage her medications. Although Maria was already using Access LA, which provides transportation services for people with mobility needs, Sandy was able to give Maria coupons so that she can now use it for little or no cost.
Sandy will continue to check in with Maria on a regular basis, to make sure she has the supplies she needs, and to ensure that she’s in regular contact with her healthcare team. And as for those calls to the emergency services? Maria hasn’t called 911 since May.
For more information on the collaboration between Partners and the LAFD NPRU, please click here.
