Tracy House, KHP Outpatient Care Coordinator, developed a working relationship with an elderly couple from London, Ky. last year. The couple was referred to KHP through their Humana MA insurance and the Humana nurse who visits monthly. Right away, Tracy was able to help connect with United Way to get the couple a ramp, begin home meal delivery, help facilitate payment of outstanding medical bills, and assist with limited transportation.
This summer, the wife was referred for hip surgery at Saint Joseph Hospital London and rehab in a skilled nursing facility. As the primary care giver, she was unable to leave her husband who could not stay home alone. Tracy stepped in to assist. She worked with Humana, both patients’ primary care providers, VNA Health at Home, and the Saint Joseph Hospital London social worker to navigate needed approvals and coordinate options.
Just in the nick of time – the day of surgery – the husband was approved for skilled nursing facility rehab! Tracy and team were able to coordinate placement for the couple, together. After a 20 day stay, they were discharged home. Tracy again worked with the skilled facility planner to coordinate home health care for both the husband and wife, as well as medical equipment, medications, home meals and follow up appointments with their primary care provider. She even made a home visit to make sure all was going well and to provide some education. Thanks to the personalized support from the KHP team, the couple is doing well.
The patients’ providers at MD2U agreed, “Tracy’s hard work to coordinate care for our patients made a significant difference for this couple. Patients often can’t appreciate the benefit of having support from a care management team, unless they’ve had to coordinate their own care in the past.”