It was about eight months ago that Marilyn moved to Providence. She was so sick she couldn’t live by herself anymore, so her sister took her in.
“She’s got end-stage renal disease, depression, anxiety, she’s bi-polar, hypertensive, and [has] thyroid problems as well,” explains Cristiana Ordonez, a registered nurse and Transition Care Manager with Neighborhood Health Plan of Rhode Island.
Marilyn ended up meeting Neighborhood’s transition team after one of her recent hospital stays last December.
“She does have a lot of needs,” Cristiana adds. “And one of the things she was telling me was she had been falling quite often.”
Getting Marilyn a new walker was an easy solution to stop her from falling. But she’s also on peritoneal kidney dialysis, which she administers herself, five times every day. Part of one room in Marilyn’s apartment is dedicated just to storing those supplies. Keeping her up-to-date on how to best do her own treatments takes a lot of work all by itself.
“I don’t feel overwhelmed,” Cristiana says. “I kind of take one challenge at a time and we work together.”
“Our main focus is to minimize [our members’] hospital stays,” adds transition team member Vanessa Vigil.
The team helped Marilyn find a Spanish-speaking psychiatrist and they’ve given her a LifeLine medical device that she can wear around her neck. In case she falls again, Marilyn can press a button on the LifeLine and summon an ambulance immediately.
“Neighborhood has helped me a lot,” Marilyn says, using her transition team as translators; she speaks very little English. “It has helped me get the equipment I need.”
But this team knows keeping Marilyn healthy is hard. They have to keep an eye on what are called the “social determinants” of health: what is it about the member’s environment that helps or blocks them from doing what they need to stay healthy?
“Meeting any needs, removing any stressor, makes them focus more on their health,” Cristiana explains. “Because if you don’t have to worry about, ‘Do I have food, do I have heat?’ then you have the ability to worry about, ‘How do I keep myself healthy?’”
This winter, the heat was a problem. Vanessa Vigil, the transition team’s Community Outreach Specialist, showed up to Marilyn’s apartment for the first time to find Marilyn and her sister bundled up in coats; their heat had been shut off for lack of payment.
Vanessa saw a challenge: “Me personally? I’ll go out, wherever I need to go, to get whatever the member needs.”
She’s not kidding. She wasted no time meeting with community agencies who she knew had the power to help. Vanessa’s relationships with The Providence Community Action Agency resulted in Marilyn’s heat getting turned back on immediately — and they even helped pay down her bill. Vanessa next turned to the St. Vincent de Paul Society, who offered support with Marilyn’s electric bills.
If it sounds like work that your average health insurance company doesn’t typically do, Vanessa agrees.
“There’s a lot of case management agencies, but they definitely don’t do what we do,” Vanessa says. “We’re very involved, we go out to the home, and we see the member face to face. We make a big, big difference as a company.”
Neighborhood is currently working on finding Marilyn a subsidized apartment where she can live with her sister as her primary caretaker. Vanessa’s looking for a first-floor unit for Marilyn, so she doesn’t have to navigate the steep stairs to a second-floor apartment like she does now.
“For me, growing up in this community, I know what it is to struggle,” Vanessa says. “It’s nice to see that I can make a difference.”
Marilyn says Neighborhood’s help has changed her life. “It gives me a lot of strength, a lot of motivation, and I’m very grateful,” she says.
Cristiana says Marilyn “is doing wonderfully well; she hasn’t been in the hospital for over a month.”
Once a Neighborhood member is stable, they typically get discharged to a Case Management team, who continue to assist in their recovery. That’s where Marilyn is today.
“I’m very happy with her progress,” Cristiana adds.
For Marilyn’s part, although she refers to Cristiana and Vanessa by their given names, she also calls them something else: