Member Case StudyCeleste's journey to health and home support with Cleo

Celeste's story

Celeste* is a 72-year-old high-risk member of a Medicare Advantage Plan. She enrolled in Cleo following a telephonic outreach and presented with multiple complex health and social challenges.

Celeste was assessed as High Risk due to a poor self-assessment of her health, a history of stroke, polypharmacy, and recent falls. She required significant support for nearly all ADLs and IADLs, including dressing, bathing, preparing meals, and taking medications as prescribed. While she lives with a supportive spouse who is her caregiver, she still reported acute symptoms of anxiety and depression and demonstrated a need for improved nutrition and consistent home support.

Despite these barriers, Celeste was motivated to improve her health, open to dietary changes, and showed initiative by planning to contact a home health agency.

 

*Names haves been changed to protect the identity of the member.

Getting set up

Celeste connected with her Cleo Medicare Coach, Mirline, through a telephonic enrollment. Her initial Health Pulse identified her primary risks across physical, mental, and social wellbeing dimensions. Working with her Coach, Celeste articulated her vision:

“I want to live a healthier life by eating better and getting the help I need at home so I can feel stronger and more independent.”

Together they established the following key focus areas and SMART goals:

  • Focus Areas: Nutrition improvement, chronic condition management, and access to home health support.
  • SMART Goal 1: Member will contact a home health agency within one week to initiate services.
  • SMART Goal 2: Member will incorporate at least one additional serving of vegetables and one serving of fruit into daily meals for the next 4 weeks.

Securing care

Celeste’s Coaching Plan centered on providing immediate motivational support for her self-identified goals, while also reinforcing positive lifestyle changes for long-term stability. The Coach engaged in weekly follow-ups to ensure momentum was sustained.

Establishing essential home support

The Coach focused on quickly transforming Celeste’s initiative into action by guiding her through the process of securing essential home care services.

  • The Coach followed up diligently to encourage and guide Celeste to make the critical first contact with a home health agency.
  • This timely support addressed her most urgent need for help with ADLs, directly mitigating her fall risk and reducing the burden on her spouse/caregiver.

Fostering sustainable nutrition habits

Celeste was open to dietary changes, so the Coach worked collaboratively to make her nutrition goals realistic and achievable within her current lifestyle.

  • The Coach provided nutrition education materials focusing on easy and affordable ways to incorporate fruits and vegetables into her daily meals, directly supporting her second SMART goal.
  • They collaboratively set realistic and measurable goals that aligned with her stated desire to “live a healthier life by eating better.”

Long-term stabilization

The long-term coaching strategy involved monitoring the continuity of her home health care and reinforcing the positive dietary changes to promote overall stability and wellness.

Success metrics achieved

 

  • Home Health Established: Home health services through an agency were successfully established.
  • Consistent Support: Provider visits occur twice weekly, assisting with daily living activities and personal care.
  • Goal Engagement: Demonstrated initiative and followed through on contacting her home health provider.

Health & quality of life improvements

Through dedicated coaching and successful goal achievement, Celeste experienced immediate improvements in her home life and overall sense of wellbeing, setting a foundation for long-term health management.

  • Improved Medication Compliance: Provider visits twice weekly supported medication adherence, critical for her polypharmacy and chronic conditions.
  • Reduced Stress & Overwhelm: Increased support has reduced household stress for both Celeste and her spouse/caregiver, promoting a more stable home environment.
  • Focus on Wellbeing: Celeste reports feeling more supported and less overwhelmed. The assistance with cooking and cleaning allows her to focus more on her personal health goals and overall well-being.

 

Empowerment and support

By supporting Celeste in achieving her goals for home health and nutrition, the Coach helped stabilize her home environment and provided her with the crucial support needed to manage her complex chronic conditions. She is now on a path to sustained improvement, feeling stronger and more independent.

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