1. Health Homes

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

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

4. 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

5. 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

6. Some days, this job is immensely difficult.

7. 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.

8. 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.

9. 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…

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

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

15. “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.”

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

19. “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.”

21. 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.”

22. “I appreciate you, thank you.”

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