There was a time – only 18 months ago – when Neighborhood Health Plan of Rhode Island member Altagracia was barely comfortable sitting on her own front porch.

“Yes,” the Providence woman says through an interpreter. “I was very, very scared.”

Altagracia was diabetic, hypertensive, in need of 21 dental extractions – and still recovering from her fourth heart attack in three years.

“She also was severely depressed and very anxious, and because of that she was not able to get on the bus to get to her medical appointments,” explains Terri Venditto, RN, a Medical Case Manager with Neighborhood. “So she was actually not really engaged with her providers at all.”

Like many Neighborhood members who are medically fragile, Altagracia was referred to the Integrated Care Management Team.

And – also like most everyone else on that list – she proved exceptionally hard to contact.

“We tried to reach out to her in May 2015 and it took over 11 tries to actually reach her,” Terri says. “We left her numerous telephone messages, we sent her letters and we did two unexpected and unscheduled home visits.”

For this team, that’s normal.

“With the experience that we have with behavioral health, it often takes many tries to actually engage someone,” Terri says. “In this case it took I believe it was eight months of actively trying to reach out before we were able to get her to be consistently and continually engaged in our program.”

From Altagracia’s perspective, the attention from Neighborhood caught her off guard.

“My first impression, when they first came to my door [was that] I didn’t want to see anyone,” says the native of the Dominican Republic. “I didn’t want to engage. I was in pain and wasn’t prepared. It was hard to talk to anyone.”

But the team broke through in a uniquely Neighborhood way:  two of the four team members are native Spanish speakers. Noel Hernandez, one of Neighborhood’s Community Outreach Specialists, did what he does best: communicates.

“I was able to start little small talk, you know, complementing little things around the house,” Noel says. “I think the fact that she was able to see me as …Hispanic, you know, I think she felt very comfortable having someone speaking her language. And I was able to identify with her to a certain extent.”

Ruben Tejada, another Neighborhood Community Outreach Specialist and native Spanish-speaker who works with Altagracia, agrees.

Ruben explains: “When I talk to [our Spanish-speaking members], a lot of times they really just need someone to talk to and offer support. And then through that, I can get them going to their doctors, making sure they’re keeping up with their appointments, making sure they’re taking the proper medications.”

For the Integrated Care Management Team, building relationships with Neighborhood’s members is vital to the entire care plan.

“Once we are able to get our foot in the door, we have been able to get them what they really need,” Terri adds. “They have to feel comfortable and get that trust built. And we do that.”

Neighborhood helped Altagracia find a dentist who could treat her, as well as a new cardiologist with whom she felt more comfortable. Her anxiety subsided, and she was willing to travel to the doctor again.

For Altagracia, the change has been dramatic.

“Where she is today, from where I met her, it’s an incredible change,” Ruben says.  “Incredible!”

“I feel excellent, I feel great, different from a year or two ago,” says Altagracia. “I feel happy now. I have a motivation to keep living, motivation to keep going, I have a beautiful family and because of them I must live.”

“It’s incredible, she’s a different person,” adds Noel.

“Of course, it is very important to have Neighborhood as my health insurance,” Altagracia says. “It’s like the passport to life.  Without it, I would not have accomplished anything. I don’t know how to say thank you, but thank you!  Thank you!”