Health Homes

Care Coordinator Program Comprehensive Care Management Health Promotion Care Coordination Individual and Family Support Transitional Care Referral to Community Resources

During the Month of July 2017 433 Face to Face Visits During the Month of July 2017 470 in August 2017

We met with them: …we met them where they were In parks, on walks At the cemetery, the casino At the hospital, the emergency room At the dentist, at the doctor, with the specialist At the kidney center, at the cancer center In their homes, apartments, shelters, rooms At assisted living, adult family homes, nursing homes At the Senior Center, at Adult Day Health In various office, at coffee shops …we met them where they were

Establishing goals for better health We helped people with Establishing goals for better health Reducing hospitalization and ER visits Mental health services, support groups Hospice/Palliative Housing, moving, placement Locating supplies, DME Accessing LTC services Social security, DPOA, Living Wills Finding legal services Insurance and eligibility issues Transportation Finding new doctors, specialists Making appointments and phone calls Deciphering incoming mail Getting information, getting glasses Their pets Coordinating with case managers Finding dental resources Referrals

Some days, this job is immensely difficult.

In addition to the logistics of managing our hefty caseloads while meeting program requirements, the emotional weight is heavy. We are often the people our clients call to share their successes as well as their setbacks and losses.

It is a difficult journey, often uphill, that we walk together It is a difficult journey, often uphill, that we walk together. But it is because of these relationships, which we often spend months fostering, that we keep coming back to work day after day.

Just as we support and encourage our clients, they give us the strength to continue. Their words of appreciation and demonstrations of growth and insight are why we do this…

“I was going to cancel today, but I remember you always make me feel better.”

“It’s nice just talking to you, I feel like these monthly meetings give me motivation.”

“Thank you for visiting, no one else comes to see me.” “A friendly face!” “Thank you for visiting, no one else comes to see me.”

“If it weren’t for you, I don’t know where I’d be - probably jail or the hospital.”

“It seems we will not make it to three years but the time I have had with you has become one of my favorite hours of the month.”

From a journal entry a client shared with a care coordinator: “As I went over my day and my visit with her I realized that I had become calmer and more focused and aware of my surroundings and realized I must let go so I can become more trusting. Trusting in myself first, lighten the load and dance from within. You can do it. ‘No’ is part of life.”

“I appreciate you, thank you.”

Music Credit “With My Own Two Hands” By Ben Harper