Barbara chooses Neighborhood Health Plan of Rhode Island. That means when she interacts with her health insurance company, it’s typically with welcoming hugs at the front door of her Warwick apartment.

“People in [my building] say, ‘You’ve got to be the luckiest person in here!’” Barbara says.

Every six weeks, the “Two Tracys” from Neighborhood pay Barbara a visit.  Tracey (with an “e”) is a Nurse Practitioner and Tracy is a Certified Community Health Worker.

At each visit, they women check Barbara’s blood pressure, take her weight and temperature, listen to her lungs, and have a long conversation about how she’s feeling and what she needs to stay healthy.

“We encourage the preventive care versus the reactive care,” explains Tracey, the Nurse Practitioner.

Barbara gets this level of attention because, as someone dually eligible for Medicare and Medicaid, she can be part of Neighborhood’s Health@Home program, which is meant for members most likely to need a lot of care. Health@Home’s team works with members’ primary care providers.

“We are not taking over any existing care that [members] have,” Tracey points out. “We are adjunct to that, in the home.”

Barbara is in generally good health, but a few months ago, she took a terrible fall.

“I hit my head, and then by the time they took me to the hospital I had a hematoma that was the size of a big orange on the side of my leg,” Barbara recalls.

After eight weeks of rehab, Barbara’s phone rang. It was Neighborhood, offering the opportunity to take part in Health@Home. She immediately said yes.

Tracey, the Certified Community Health Worker “just knew it was going to be a great relationship” the first time she stepped into Barbara’s apartment.

Barbara felt the same way.

“It has been one great experience after another,” Barbara says. “Anytime I need something, they are right there. They are right there if I have a question or if I need something. They’re always there.”

From Neighborhood’s perspective, that’s the goal.

“When that home connection is made, with only about three or four visits, she has opened not only her home but her heart to us,” Tracey says. “And so the connection was made right away, where we could just almost immediately help her with some daily needs.”

During every home visit, Barbara has a chance to ask her team whatever medical questions she has.  At one recent visit, she had a straightforward question: Could the women show her how to work her new asthma inhaler?  Her doctor had demonstrated it in the office, but once Barbara got the new device home, she couldn’t get it to work. The Health@Home team was able to assist with this small, but meaningful, request in the same way they can help Barbara manage all of her needs.

“They come, and we can sit and we can talk,” Barbara says. ”I can voice whatever I am going through. They tell me what is available to me. So it’s a two-way street and I love the both of them. I love the both of them!”

Home visits are an investment, but they’re worth it to Neighborhood and to our members.

“The health maintenance factor is really important,” Tracey says. “Not only does it keep [members] out of the hospital, but it keeps costs low.”

In fact, Health@Home saves Neighborhood about $2 million a year, in part by helping members avoid unnecessary trips to the emergency room and unneeded inpatient hospital stays. But from Barbara’s perspective, she’s just delighted she’s got people looking out for her.

“I feel like I have two best friends that will answer any question I have. If they don’t know the answer, they will find the answer,” she says.

For the Health@Home team, making that connection and solving those problems makes theirs an incredibly rewarding job.

“It’s a wonderful feeling. It’s just amazing to be able to go into somebody’s home and help them and to make even just the smallest difference,” Tracy explains. “It’s amazing.”