Member Case StudySusan's journey to independence and care access with Cleo

Susan's story

Susan* is a 69-year-old high-risk member of a Medicare HMO. Referred by her health plan, Susan presented with multiple acute physical and mental challenges that were severely limiting her independence and quality of life.

Susan was struggling with significant mobility issues and difficulty with most ADLs, compounded by a history of falls and compromised skin due to fecal incontinence. Her diabetes was dangerously uncontrolled, with fasting blood sugar running in the 300s (and once spiking over 600 during a recent hospitalization). She was prescribed over 24 medications. Despite being self-aware and highly motivated, she lacked family support (all family lives out of state) and was unable to follow up on critical care recommendations due to quoted out-of-pocket costs (e.g., a $200 co-pay).

Her vision was clear: “I just want to be able to take a shower and understand what’s happening with me.”

 

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

Getting set up

Susan connected with Cleo Medicare Coach, Jasmine. The Coach quickly identified the need for a high-engagement frequency (1-3 times per week) across all dimensions of wellbeing (Physical, Mental, and Social). The initial focus was on building trust as Susan was apprehensive to share specific information.

Her primary goals were to remove financial and logistical barriers to care:

  • Focus Areas: Locate an INN center for an anorectal manometry to avoid the $200 co-pay; find a local INN PCP (she was traveling over 40 miles); and secure a home health order to address her multiple deficits.
  • SMART Goals: Member will complete rescheduled anorectal manometry within two weeks, and follow up with a home health agency to initiate requested services.

Securing care

The coaching plan focused on intensive, short-term support to quickly coordinate essential services and educate Susan on navigating her health plan benefits to avoid future cost barriers. The Coach immediately targeted the crucial, previously canceled diagnostic test:

  • The Coach successfully located an INN center to complete the anorectal manometry, which was completed within two weeks of enrollment with no out-of-pocket costs.
  • This intervention not only solved the immediate financial hurdle but also started building Susan’s trust in the Coach and her health plan’s ability to coordinate affordable care.

Coordinating comprehensive home health

To address Susan’s complex physical and medication needs, the Coach coordinated a multi-disciplinary home health team:

  • The Coach requested home health services, securing Nursing (for disease/medication management), Occupational Therapy (OT) (for ADL training, especially showering), and Physical Therapy (PT) (for strengthening and ambulation).
  • This allowed an RN to begin working on her uncontrolled blood sugar and medication regimen.
  • The Coach later coordinated a transfer to a new agency at Susan’s request to ensure she had a female OT to assist with bathing, demonstrating personalized support.

Establishing local, coordinated care

The Coach addressed the logistical issue of Susan traveling long distances for appointments:

  • The Coach successfully located and established a new INN PCP near Susan’s residence.
  • The Coach completed a conference call with her provider to report her recent fall and assisted Susan in verbalizing her concerns and her difficulty managing her complex medication list.

Success metrics achieved

Through high-intensity, personalized coaching, Susan quickly stabilized her condition, gained independence, and achieved a major quality of life goal.

  • Diagnostics Completed: Anorectal manometry completed (with no out-of-pocket cost).
  • Comprehensive Support: Home health services (Nursing, PT, OT) are in place.
  • Local Care Established: New PCP established within her requested area.

 

Health & quality of life improvements

 

  • Independence Restored: Member reported increased mobility. As of July 2025, she was able to attend the water aerobic classes at her local community center.
  • Safety & Function: A home safety assessment was completed, and DME recommendations were submitted to improve her safety and function.
  • Improved Confidence: Member reported her blood sugar still fluctuates, but she is more confident since working with the home health RN on disease and medication management.

 

Empowerment and support

By immediately eliminating financial barriers and coordinating comprehensive home health and local primary care, the Coach directly addressed Susan’s core needs (showering and understanding her health) and empowered her to achieve goals that significantly improved her quality of life and physical activity.

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