Member Case StudyJuan’s journey to reconnection and support with Cleo

Juan' story

Juan is a 72-year-old member of a Medicare HMO C-SNP. Despite being assessed as Low-Risk by his Health Pulse assessment, Juan was grappling with significant social and mental health challenges that were directly impacting his physical care.

Juan lives alone and reported feeling isolated following his son’s recent job change, which reduced their contact. He verbalized a history of anxiety and depression and experienced frequent feelings of loneliness. This mental and social strain was compounded by a critical physical barrier: a lack of reliable transportation had caused him to miss medical appointments, including a crucial follow-up for a significant change in his vision.

His vision statement captured his emotional distress: “I just want to feel like myself again, I feel like I have no one to talk to.”

Getting set up

Juan connected with Cleo Medicare Coach, Jasmine. Initially, Juan was apprehensive about sharing specific concerns. However, by the fourth call, the Coach had built enough trust for him to open up about his depression, anxiety, and recent feelings of isolation.

The Coaching Plan, adjusted to an every 1-2 week engagement frequency due to his mental health needs, focused on addressing the underlying issues of isolation and lack of access.

  • Focus Areas: Locate community center for socialization; secure non-emergency medical transportation; and identify behavioral/mental health support.
  • SMART Goals: Attend paratransport intake appointment for non-emergency medical transportation setup; attend community center open house to assess activity offerings.

Securing care

The long-term coaching plan was dedicated to helping Juan understand the healthiness of addressing his mental health and supporting him in identifying and utilizing social and medical resources.

Addressing social isolation and loneliness

The Coach prioritized connecting Juan with community resources to combat his feelings of loneliness:

  • The Coach successfully located a community center that provided two essential resources: transportation to the center and communal dining for socialization.
  • Juan attended the open house event and began attending a monthly exercise group, actively working to decrease his risk of isolation.

Removing transportation barriers to care

To ensure Juan could address his vision concerns and future medical needs, the Coach coordinated reliable transportation:

  • The Coach coordinated non-emergency medical transportation and simultaneously located an INN ophthalmologist for the member’s long-overdue eye exam.
  • This direct intervention allowed him to complete his annual vision exam.

Facilitating mental health access

Building on the trust established, the Coach helped Juan find professional support for his anxiety and depression:

  • The Coach located an INN mental health professional and, to ease his apprehension, assisted the member with the virtual intake process.
  • This led to him accessing a mental health provider and receiving appropriate medications to address his anxiety and depression.

Success metrics achieved

The combined interventions immediately addressed Juan’s social and logistical barriers, resulting in measurable improvements in his health and overall outlook.

  • Full Access to Care: Transportation barrier addressed, and member completed his annual vision exam and accessed a mental health provider.
  • Social Connection Secured: Member connected with a community center for socialization and began attending an exercise group.
  • Mental Health Support: Accessed mental health professional and began treatment (medications received).

Health & quality of life improvements

 

  • Vision Restored: Member received corrective lenses to address his vision concerns, directly improving his daily function and safety.
  • Emotional Relief: Member reported a decrease in feelings of loneliness.
  • Shift in Mindset: Juan stated, “Thank you for listening, I’m more motivated to find solutions rather than focus on the negative things.”

 

Empowerment and support

By listening, building trust, and coordinating services that addressed his anxiety, isolation, and lack of transportation, the Coach empowered Juan to overcome his emotional barriers and actively engage with the solutions needed to restore his health and confidence.

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