Member Case StudyRuby's path to medication stability with Cleo

Ruby's story

Ruby* is a 79-year-old high-risk Medicare member who was referred to Cleo by her health plan after her spouse called in seeking support.

Ruby presented with a complex profile of risks: she manages five chronic conditions (including dementia/Alzheimer’s and depression), uses multiple medications (polypharmacy), and was struggling with medication non-adherence. Critically, she experienced frequent dizziness, which contributed to a substantial fall risk and led to repeated, unnecessary ER visits and hospitalizations in the last year. While her Physical Wellbeing risk was high, she benefited from a strong support network, including her spouse as a main caregiver, a daughter, and established home health services (Nursing, PT, OT, ST).

Her primary, immediate goal was to address her dizziness and stay out of the hospital and ER.

 

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

Getting set up

Ruby and her spouse connected with Cleo Medicare Coach, Kimberly. Her initial Health Pulse score confirmed her High Risk status, specifically noting significant cognitive decline, poor activity level, and a lack of preventative care engagement, including no recent annual wellness exam or medication reconciliation.

Given her immediate crisis (dizziness and hospitalization), the Coach and caregiver quickly focused on the most critical needs:

  • Focus Areas: Addressing dizziness, reducing falls, and preventing unnecessary hospital/ER utilization.
  • Long-Term Goal (established by Coach): Address the immediate needs of Ruby and her spouse/caregiver.
  • SMART Goals: Due to the acute nature of the issue, the primary action was the coaching intervention itself, leading directly to measurable outcomes.

Securing care

The coaching strategy focused immediately on a high-value, targeted intervention to stabilize Ruby’s physical symptoms. The engagement frequency was set to once a month, as requested by her spouse.

Identifying the root cause of crisis

The Coach recognized a critical gap in Ruby’s care management that was driving her symptoms and hospitalization:

  • The Coach identified a possible correlation between Ruby’s polypharmacy, the reported symptoms of dizziness, the lack of an annual medication review, and the multiple hospital/ER visits.

Facilitating medication reconciliation

The Coach worked directly with the primary caregiver, who held the power to coordinate care, in order to address the medication issue:

  • The Coach educated the caregiver on the critical importance of an annual medication review to prevent adverse drug events and interactions.
  • The Coach guided the caregiver to immediately schedule an appointment with specialists for a comprehensive medication review.
older medicare advantage couple caregiving

Success metrics achieved

 

  • Medication Reconciliation Completed: The annual medication review was successfully completed by specialists.
  • Reduced Polypharmacy: The review resulted in reduced medication dosages and the removal of some medications entirely.
  • Behavioral Change: Increased medication adherence by the member and her caregiver.
  • Hospital Utilization Reduced: Reduced unnecessary ER/hospitalization was achieved.

 

Health & quality of life improvements

The targeted coaching intervention resulted in immediate, profound improvements in Ruby’s health, daily function, and healthcare utilization.

  • Dizziness Eliminated/Reduced: The member now experiences significantly reduced dizziness.
  • Falls & ER Visits Stopped: The member is now not falling and has had no ER visits or readmissions within 30 days after her last discharge.
  • Improved Daily Functioning: The reduction in dizziness and falls has resulted in improved daily functioning and quality of life.
  • High Satisfaction: Member reported satisfaction with the Health Plan and retention was supported.

Empowerment and support

By focusing on the high-value intervention of medication reconciliation, the Coach not only solved the immediate, life-threatening symptoms of dizziness and falls but also helped Ruby stay out of the ER and hospital, demonstrating the powerful impact of coordinated care on patient safety and healthcare costs.

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