People with multiple chronic conditions typically have more doctors’ appointments and emergency room visits than most people, but many also suffer from limited mobility that makes travel difficult. A special program called HomeAdvantage, in partnership with Landmark Health, brings health care to these patients at home whenever they need it. Care teams comprised of doctors, nurses and other specialists make scheduled “house calls” to members’ homes for check-ups and treatment. Team members are also available by phone 24/7 and can make urgent on-call visits as needed. This helps keep people healthy at home – where they want to be – and out of emergency rooms, hospitals and long-term care facilities, where stress and contagion can make them sicker.
HomeAdvantage has already helped more than 1,100 Health Plan of San Mateo (HPSM) members. This unique service is available at no cost, through a partnership with Landmark Health, to eligible CareAdvantage members – dual eligibles with both Medi-Cal and Medicare – who have five or more chronic conditions. Here is one of their stories.
From immobile & isolated to active & independent
At age 55, a stroke left the right side of Marijo Peterson’s body virtually paralyzed. From then on, she could no longer work as a recruiter of caregivers for a health agency – instead, she needed someone to take care of her. She couldn’t dress, shower or cook for herself, much less leave the house alone. Marijo’s husband became her primary caretaker and did all the household chores while working full-time. Marijo also didn’t have health insurance, so she couldn’t get the treatment she needed to recover from the stroke or for the asthma, diabetes and heart disease she developed as a result.
“I felt so isolated, confused and angry,” Marijo said. “As if the world just hates me.”
Marijo didn’t get disability payments for the first two years after her stroke, and the couple couldn’t afford to pay for caretakers. Friends helped, but Marijo spent most days alone at home. She also had to wake up, get dressed, eat and do everything else around her husband’s schedule. The reality that Marijo’s safety was at risk hit home when she fell and couldn’t reach her phone. She waited on the floor, in pain and fear, until her husband came home.
In 2012, more than two years after her stroke, Marijo got health insurance through HPSM’s CareAdvantage program. In May 2017, she started getting regular home visits from her HomeAdvantage provider, Mary Knopf, a Family Nurse Practitioner (FNP) with more than two decades of experience caring for patients.
During Marijo’s first home visit, Mary listened to her story so she could understand her situation, identify gaps in service and create a treatment plan to enhance Marijo’s quality of life. “To increase her mobility, I recommended occupational therapy and at-home physical therapy,” said Mary. Since then, Marijo has been walking around the house and on the sidewalk. To increase her independence, Mary arranged for an In-Home Support Services (IHSS) caregiver to help Marijo several times a week with cooking and shopping, giving her more time and energy to socialize with friends. “We are patient-centered,” said Mary. “I help Marijo figure out what we can do or bring in to enhance her quality of life.”
Mary tracks Marijo’s progress through regularly scheduled home visits that include routine check-ups, treatment and medication checks. She then coordinates with Marijo’s PCP, specialists and therapists to find out what they’re doing and communicate a big-picture view of her treatment. But HomeAdvantage also provides Marijo with peace of mind, because if she has any health problems, help is just a phone call away – anytime of day or night. For instance, she had trouble breathing one night, but with a quick call to HomeAdvantage, a Landmark physician was soon at her home helping her breathe normally again. “Without HomeAdvantage, I would have had to go to the ER,” Marijo says. “Which means driving there and waiting to be called while I still can’t breathe right. HomeAdvantage makes getting help faster, safer and much less stressful.”
HomeAdvantage also helps prevent the “snowball effect” that can happen when a patient goes from the ER to a stay in the hospital that can last days. At that point, the patient may be so weak that it’s not safe for them to go home alone, and they wind up in a nursing home. HomeAdvantage stops that cycle before it even starts.
HomeAdvantage’s scheduled home visits, 24/7 phone support and urgent house calls support Marijo’s recovery by giving her the treatment she needs, more control over her life and the security of knowing help is always available. In her own words, “The comfort of having HomeAdvantage is really amazing.”