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At ARC Coordinating Care is More Than Scheduling Appointments

My story is one of care coordination. My patient has multiple chronic illnesses. Last year he started having problems with memory, hallucinations, and headaches, which were quickly worsening. I was able to get him established with a specialist for vascular dementia. He had been hospitalized numerous times and it became clear to me after one of these admissions that he was falling through the cracks in the healthcare system. I worked with the hospital and health plan case managers. I was able to get him home health and a psychiatric nurse who helped coordinate difficult family dynamics. We also involved APS and DADS. In the end, we were able to confirm his eligibility for nursing home care and he was admitted. I spoke to him after that and he shared he was happy to have a secure and stable facility to help care for him.

Tags: Medical Home

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