Member Case StudyPaige's path to safety and self-sufficiency with Cleo

Paige's story

Paige* is a 74-year-old member of a Medicare PPO plan. While diligent about her preventative care and medication adherence, Paige faced a combination of physical, social, and systemic challenges that left her feeling isolated and unable to perform basic daily activities.

Living alone on a low income, Paige grappled with chronic pain, depression, and significant difficulty with Activities of Daily Living (ADLs)—most notably, she was unable to feed herself easily due to severe swelling and limited range of motion in her upper extremities. A history of falls with injury made her home feel unsafe. Compounding these issues was a profound distrust in the healthcare system, born from confusing and costly experiences that prevented her from accessing necessary care, including a critical rheumatologist appointment.

Her vision was clear and urgent: “I just want to be able to feed myself easily and not worry about falling in the kitchen and bathroom.”

 

*Names have been changed to protect the identity of the member

Getting set up

Paige connected with her Cleo Medicare Coach, Jasmine. Her Health Pulse results placed her at High Risk, prompting the Coach to engage weekly to address her acute needs.

The immediate focus was on resolving the benefit misunderstandings that were blocking her access to care and addressing her urgent home safety concerns.

  • Focus Areas: Re-establishing access to rheumatology care; mitigating fall risk in the home; and addressing ADL dysfunction, particularly the need for functional splints to enable self-feeding.
  • SMART Goals: Complete ordered bloodwork and reschedule rheumatologist follow-up within 2 weeks; meet with PCP to obtain an OT/PT order and discuss memory concerns within 2 weeks; implement home safety recommendations provided by a community health clinician.

Securing care

The Coaching Plan centered on rebuilding Paige’s trust by demonstrating the value of her health plan and coordinating directly with providers to resolve immediate barriers. The Coach performed multiple high-value interventions that simultaneously addressed care access, safety, and ADL deficits.

Re-establishing access to critical care

The Coach directly addressed the financial barrier that caused Paige to miss her specialist appointment:

  • The Coach located an in-network lab where Paige could complete her ordered bloodwork with no out-of-pocket cost, removing the $150 fee that had previously blocked her. This allowed her to reschedule and attend her vital rheumatologist follow-up.

Addressing ADL deficits and chronic pain

Recognizing that Paige’s inability to use her hands was a primary source of distress, the Coach facilitated a direct line of communication to her provider:

  • The Coach conducted a three-way conference call with Paige and her PCP, coaching the member through her request for support. This call resulted in the approval and coordination of a home health order for Occupational and Physical Therapy (OT/PT) to address ADLs, pain, mobility, and the need for new functional splints.

Enhancing home safety and reducing fall risk

To immediately address Paige’s fear of falling, the Coach found a solution within her health plan benefits:

  • The Coach helped coordinate a home safety assessment, which provided the clinical justification for her health plan to cover appropriately sized non-skid mats through her OTC benefit, securing her kitchen and bathroom floors.
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Success metrics achieved

Through swift, hands-on support, Paige achieved all her short-term goals, re-engaging with the healthcare system and seeing immediate improvements in her daily life.

  • Critical Care Accessed: Member successfully completed bloodwork and attended her rheumatologist follow-up, leading to management of a painful flare-up.
  • Immediate ADL Support: Successful approval and initiation of home health OT/PT services resulted in decreased pain, improved mobility, and an increased ease with self-feeding.
  • Home Safety Secured: Member received and implemented appropriate non-skid mats, significantly decreasing her risk of falls.

Health & quality of life improvements

 

  • Increased Health Literacy: Member reported an improved understanding of her health plan benefits and how to navigate office vs. outpatient services to avoid future costs.
  • Restored Trust: Member reported feeling included in healthcare decisions and expressed increased confidence in managing her chronic conditions.
  • High-Quality Care: Member accessed high-quality specialist and therapy services that were previously blocked by financial and logistical hurdles.
  • Cognitive Improvement: With her chronic pain better managed, Paige reported improved concentration and memory.

 

Empowerment and support

By directly clarifying Paige’s benefits and acting as a liaison with her providers, the Coach not only solved her immediate physical and safety needs but also began to repair her foundational trust in the healthcare system. This holistic approach helped move Paige from distress and isolation toward achieving her goal of safety, self-sufficiency, and empowerment in her own care.

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