Member Case StudyFiona's journey to collaborative care with Cleo

Fiona's story

Fiona* is a 71-year-old high-risk member of a Medicare PPO. Enrolled following an outreach, Fiona faced a dire health crisis complicated by communication breakdowns and financial distress.

She was actively battling gastrointestinal cancer (in remission for breast cancer) and experiencing failure to thrive. She was receiving most nutrition through a j-tube, but severe complications—including leakage, pain, and dislodgement—led to 2-3 hospitalizations per month and significant weight loss. Compounding her physical issues, she struggled to manage nausea medication due to involuntary purging and felt caught in the middle of a conflict: her two oncologists (one for each cancer) were not agreeing on her current treatment plan. Fiona was also struggling with low income and substantial medical bills.

Her vision was rooted in hope and purpose: “I want to get over this, I want to be able to maintain my weight and share my story.”

 

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

Getting set up

Fiona connected with Cleo Medicare Coach, Jasmine. Her Health Pulse results identified a High-Risk status driven by her complex physical health and concurrent mental health concerns. Despite these challenges, she had strong protective factors, including medication adherence (when able) and strong family support.

The Coaching Plan was focused on addressing immediate nutritional and medication barriers while restoring collaborative care:

  • Focus Areas: Ensuring collaboration between oncologists; obtaining financial assistance; and addressing barriers to PO intake (oral feeding).
  • SMART Goals: Follow up on an SLP (Speech-Language Pathologist) referral; attend appointments for behavioral specialist and financial assistance; schedule an oncologist appointment with her daughter for support.

Securing care

The long-term coaching strategy focused on empowering Fiona to verbalize her wants and needs and ensuring her two providers, who were part of the same medical group, collaborated on her treatment plan.

The Coach provided high-value advocacy to resolve the treatment conflict and enhance caregiver support:

  • The Coach helped Fiona develop talking points to discuss communication concerns with her oncologists, leading to the providers collaborating and agreeing on an IV treatment plan.
  • The Coach facilitated a call with Fiona and her daughter/caregiver, making the daughter aware of the barriers being faced. The daughter immediately made plans to attend future oncology visits to provide advocacy and support.

Stabilizing nutrition and medication

Addressing the immediate medical and nutritional concerns was critical to stopping the cycle of hospitalizations:

  • The Coach coordinated an SLP evaluation, which provided Fiona with compensatory strategies to better manage her oral medications, resulting in decreased purging and increased ease of tolerance.
  • The Coach located and connected Fiona with an INN dietician to discuss high-calorie food options, which helped stabilize her weight.
  • The Coach also located an INN behavioral specialist to address the potential psychological impact on her inability to tolerate oral intake.

Providing financial and emotional relief

The Coach addressed her financial and social isolation needs to support her overall wellbeing:

  • The Coach assisted Fiona with obtaining and filling out financial assistance applications for past-due medical bills.
  • A local cancer support group was located and connected to the member.

Success metrics achieved

The targeted, high-value interventions quickly stabilized Fiona’s critical condition, dramatically reduced her healthcare utilization, and restored her confidence and sense of purpose.

  • Critical Support Discontinued: Member was able to tolerate enough oral intake for the J-tube to be discontinued.
  • Provider Collaboration: Oncologists collaborated and agreed on the treatment plan.
  • Physical Stabilization: Member reported increased ease tolerating PO medications (resulting in decreased purging) and weight stabilized after working with the dietician.
  • Financial Relief: Received financial assistance for past-due medical bills.

 

Health & quality of life improvements

 

  • Increased Confidence: Member reported increased confidence in managing her current diagnosis.
  • Reduced Isolation: Felt less isolated as her daughter was now fully aware of her challenges.
  • Purpose and Advocacy: Began attending the local cancer support group and made plans to work with the coordinator to share her story with other survivors.
  • Sustained Progress: Continued to work with the behavioral health specialist and dietician for ongoing support.

 

Empowerment and support

By facilitating essential communication between providers and empowering Fiona and her daughter to advocate for her needs, the Coach not only helped her stabilize her weight and discontinue the complicated j-tube but also restored her hope—enabling her to connect with her community and share her story.

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