She is actively engaged in the plans to improve her life today, but just one year ago, Jen was not interested in any part of it.

“I really wasn’t,” explains Jen, one of Neighborhood Health Plan of Rhode Island’s 186,000 members.  “I wasn’t following directions; I kind of felt like giving up. I felt like everything was hopeless.”

Before Neighborhood, Jen was just about at her lowest point.

“I was basically a drug addict for most of my life, if not all of it,” she says.  “I was always in and out of the hospital for COPD [Chronic Obstructive Pulmonary Disease] and my mental illness.”

“When we first [met Jen], she was spending a lot of time in emergency rooms,” explains Joan Walton, a Nurse Practitioner at Neighborhood.  “When we first went out to meet with her she didn’t have a primary care physician. He had just discharged her for noncompliance, for not keeping her appointments. It was more than one appointment; it was several appointments that she just didn’t keep [and] she was using the emergency room whenever she felt sick.”

Jen admits, during her darkest days, getting to her check-ups was not a priority.  “Yes, I didn’t keep doctors’ appointments, I avoided my blood work,” she confesses.  “I really was giving up, but then my team came in to help me; I have never been healthier or happier in my entire life.”

“My team.”

That’s what Jen now calls the people with Neighborhood’s Health@Home program, who did more than she ever could have expected.

“I just love them all very much. They brought me very far in my life,” Jen says.  “Without them I think I could have been dead. I really do I think I could’ve died without them.”

Health@Home targets some of Neighborhood’s most medically fragile members – chronically ill people who are what’s called “high utilizers” of healthcare services.

A team of professionals focuses on those members’ needs, typically by going right to their homes to develop a strategy.

“Jen was a good candidate because she wanted to change her life,” Joan says. “She just didn’t know how.”

Nancy Harrison is the Director of Operations and Strategy for Health@Home.  As she describes it, “the staff is the cornerstone of the work that we do. I’ve never worked with a more compassionate group of people, more dedicated to the work that they do, and creative, because there’s not simple solutions for folks.”

For example, transportation is a problem for Jen.  Neighborhood solves the problem by connecting her with public transportation options, or even by sending a cab to get her to her medical appointments if necessary.  The team also took a look at where Jen lives, and made some medical decisions based on what would make it easiest for her to take care of herself.

“We connected her with a lab near her house” so she can get her bloodwork done regularly, says Rosanna Lavandier, the Community Health Worker from Neighborhood who is also on Jen’s personal team.  “I also gave her some information about primary care physicians, so she actually got a new primary care physician close to her house, walking distance to her house,” Rosanna adds.

According to Joan, the Nurse Practitioner, now that Jen “understands her medications, she’s more willing to take them and she remembers to take them now so her mood is better.  Her heart valve, we don’t have to worry about, because that was a life-threatening situation when she wasn’t taking that medication for these heart valves.”

Neighborhood’s team even includes a social worker, who can help address some of Jen’s mental health needs.

“I look at us as catalysts who really help our patients help themselves,” says Nancy.  “And truly that’s what I think Jen has done. We are there, and we are a support system for her, but it really has been all about Jen and what she has done to make a difference in her life and her health.”

A year after the team began working with Jen, “she’s doing great,” says Rosanna, the Community Health Worker.  “She’s compliant with her medications, she has a better relationship with her family, so she’s just a different person.”

And she’s someone who insists she’s able to do this work only because of her team.

“I’m very happy with them; I would never want to let them go,” Jen insists.  “Every time they leave I give them big hugs and kisses because I miss them.  They have brought me so very far.”