Every person is unique and has their own set of health needs. For individuals facing significant medical, mental health, or social support challenges, a helping hand can make a big difference. Having a team of nurses, community health workers, and care navigators on your side to help connect you to the services you need may improve your long-term health and quality of life.
CCA Health Michigan’s care professionals are passionate about advocating for their members, helping them break down barriers to care. For Raluca, a CCA Health Michigan care partner and registered nurse, building trust with members is key. “What helps the most is really listening to our members and taking the time to understand what they need. It lets them know that we care.”
By listening, Raluca can also develop a personalized care plan designed to address a members’ unique needs. “It’s important to get to know each member and to meet them where they are,” she said, noting their care plan must account for their reality and any struggles they may be facing.
Not long ago, Raluca met with a member named Tom* at a local emergency department (ED). Tom had been a frequent visitor to the ED and had been admitted several times. During this face-to-face meeting, Raluca did a comprehensive evaluation of Tom’s needs. She also developed a rapport with him. It was during this meeting that she learned that Tom came to the ED for more than just medical treatment. He admitted coming there often because he knew it meant getting a warm welcome and a warm meal.
By taking the time to better understand all of Tom’s needs, not just his chronic conditions, Raluca learned that he was struggling with food insecurity, as well as with anxiety and depression. He didn’t have a social support system at home that could help him with day-to-day tasks. Tom also lacked the ability to access the healthcare services he needed in a timely way. His mental and social challenges affected his physical health, and vice versa, creating a cycle that health organizations like CCA Health Michigan are working to break.
As part of Tom’s personalized follow-up care, Raluca and another CCA Health Michigan Care partner, Shannon, also a registered nurse, began checking in on him every other week. They developed a plan, coordinated his care, connected him with the appropriate health professionals, and ensured he had transportation to his medical appointments. Sometimes, Raluca and Shannon went with Tom to his appointments to make sure he understood his follow-up instructions.
Beyond helping Tom with his medical needs, Raluca and Shannon also connected him with local community resources designed to provide companionship for older, isolated adults. To help him with food insecurity, they set him up with Meals on Wheels so he would have regular, nutritious food delivered to his home.
Comprehensive care management that embraces the whole health needs of an individual can make a positive difference in the lives of people who experience diverse medical, mental health, and social challenges, especially people who are alone and isolated. Tom is just one of many people in our community who experience multiple adverse conditions that all come together and present overlapping barriers to health and wellness.
With the help of CCA Health Michigan’s care team, Tom has reduced his emergency department visits and inpatient admissions. Raluca and Shannon’s home visits helped improve Tom’s emotional health, too, as he expressed feeling less lonely and isolated. Tom eventually felt empowered enough to start taking better care of his health.
CCA Health Michigan has proven expertise in serving individuals with significant needs through Medicare Advantage plans for those who qualify for Medicare and those who are dually eligible for both Medicare and Medicaid.
Learn more about CCA Health Michigan’s Medicare Advantage plans by visiting www.ccahealthmi.org.
H9861_24_174_M CCA Health Michigan has a contract with Medicare and a contract with Medicaid. Renewal of these contracts is required for enrollment.
*Tom is a pseudonym to protect the privacy of CCA Health Michigan’s members.
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