March Success Stories

Highlighting some of the great work Titanium Healthcare Lead Care Managers, Care Coordinators, and Housing Navigators achieved in March 2024 for the California Enhanced Care Management Program, Community Supports Program, and Washington Health Homes.

“A Degree of Determination”

LCM/CC/HN/RES/Nurse: Karl

Conditions: Diabetes Type I, Hyperglycemia, Bipolar Disorder II, PTSD

Situation:  When I first encountered my 33-year-old member at a Starbucks in Tacoma last year I could tell she was intelligent and very personable. Her primary challenges were her diabetes and bipolar disorder—she also has a history of cocaine abuse, but it has been in remission for years. Upon meeting, we worked together to make sure that she had a regular mental health counselor that could prescribe her the medication for her bipolar disorder.

Outcome: She expressed an interest in working with dogs, she also expressed an interest in finishing her education, complaining about all of her failed attempts but, nonetheless all the credits she had earned with no completed degree. I asked her what kind of job she would want to do with said degree, to which she stated she would want to be a substance abuse counselor. I mentioned the idea of taking the college credits she has and completing a degree in psychology—she loved this idea and is now registered for courses at Tacoma Community College to obtain a social science direct transfer degree to continue to The University of Washington at Tacoma for a BA in psychology!

Health Plan: Community Health Plan of Washington

“Palliative Care Patience”

LCM/CC/HN/RES/Nurse: Natalie

Conditions: Early Onset Parkinson’s Disease, Chronic UTI/Kidney Infection

Situation: After months of trying to work with my 40-year-old member’s providers to get her appropriate referrals and care for her chronic UTI’s/kidney infection she was finally able to get home IV antibiotics through an infusion company. It took getting a new PCP and becoming enrolled in Palliative Care for a physician to take initiative and get her the necessary care she deserved. My member is a single mother who was reluctant to go to the hospital because she lacked a support network for her child.

Outcome: She is currently at home on IV antibiotics with the support and care of an Infusion Company, Home Health Agency, Palliative Care and ECM Program and is finally feeling some relief after constant roadblocks to the care she needed.

Health Plan: Inland Empire Health Plan

“New Chapter”

LCM/CC/HN/RES/Nurse: Ana

Conditions: Diabetes, Hypertension, Vertigo, Chronic Liver Disease, Sciatic Nerve Pain 

Situation:  My 62-year-old member has recently lost his spouse and has been feeling depressed, angry, and alone. He says he can’t rely on their children for support because they have let him down by focusing on financial matters as opposed to the loss of a parent. I offered him behavioral health support and gave him the Mental Health Crisis number which he originally declined stating that he doesn’t need that type of support at his age. Despite that, I was able to convince him that professional help is useful at any age.

Outcome: Through Carelan, I offered him several locations near his home where he can speak to a counselor to help him deal with his grief and begin a new chapter of his life.

Health Plan: LA Care

“Easy Fixins”

LCM/CC/HN/RES/Nurse: Karla

Conditions: Diabetes, Schizoaffective disorder, Weight management, Depression

Situation:  My 63-year-old member, whose sustenance relied on the delivered meals facilitated by Mom’s Meals, encountered an interruption in service due to the expiration of their authorization.

Outcome: In response, I promptly initiated the process of securing a renewed referral for Mom’s Meals. Subsequently, following swift approval, my member’s access to indispensable delivered meals was promptly reinstated.

Health Plan: Health Net

“A Shoulder to Lean On”

LCM/CC/HN/RES/Nurse: Giovani

Conditions: Epilepsy, Diabetes Type 3c, Anxiety, Shoulder pain, Joint Deterioration

Situation: My 38-year-old member has felt immense pain in his right shoulder for years and could not address it with his provider; he’s since changed medical groups and I’ve helped him obtain a referral for an orthopedic surgeon to address the issue.

Outcome: He was placed on 6 weeks of physical therapy and has regained a moderate amount of range of motion in his shoulder. He has two upcoming imaging appointments next month and after he undergoes a CT Scan and MRI his orthopedic surgeon will schedule surgery to correct the joint deterioration in their shoulder.

Health Plan: LA Care

“Pharmacy Frustration”

LCM/CC/HN/RES/Nurse: Luz

Conditions: Asthma, Hypertension, Seizures, Pre diabetic, Brain Aneurysm, Depression, Seasonal Allergies, Arthritis, Ankle swelling, High Cholesterol

Situation: During an in-person visit my 60-year-old member informed me that she has been having a difficult time getting a refill for her medication Phenobarbital. She had tried calling her Neurologist’s office and had been unsuccessful. She stated her pharmacy was unable to get in contact with them. I called the Neurologist’s office but was also unsuccessful.

Outcome: I went to her Neurologist to personally request a refill for her medication and informed the staff that we’d had trouble getting in contact with them and the pharmacy. I left a note with my member’s information and prescription for the receptionist to give to the doctor’s assistant and got an extension number to make it easier for us to contact the office.

Health Plan: LA Care

 “Nerve Pain Navigation”

LCM/CC/HN/RES/Nurse: Marie

Conditions: Desmoid Tumor, Major Depressive Disorder, Balance issues, Scoliosis, Substance Abuse Disorder, Asthma, Femoral Neuropathy

Situation: My 55-year-old member is quite reserved at our meeting and her main complaint is the constant pain that she experiences from her waist down due to what she believes is/was nerve damage from multiple history of surgeries in the past. She saw a neurologist 6 years ago, for a “nerve test” that came back “inconclusive.” Since moving back to her mom’s house, she has not seen this provider for a follow up or to get another test because she can’t drive and now it’s quite far away from where she lives.

Outcome: I first met with her in December and at that time, she was caring for her sick dog. Since the dog’s passing, she got a new puppy that keeps her busy. I was able to convince her to set up an appointment with her PCP to get a new referral for a neurologist and she just received it for Thursday 4/25/24 at 11:45 AM to determine the cause of pain and discuss possible treatments.

Health Plan: LA Care

“Eyes on the Prize”

LCM/CC/HN/RES/Nurse: Nancy

Conditions: Hypertension, Diverticulosis, Sciatica, Inguinal Hernia

Situation: My 56-year-old member set a SMART goal on how he would like to see an optometrist. Due to a busy schedule, my member was unable to find motivation to set an appointment with any optometrists from the lists that I provided throughout the past few months. He stated that he was finally able to schedule an appointment when I saw him for an in person visit on 03/15/2024. He expressed genuine excitement as we both knew this was an ongoing goal that he wanted to achieve. He’ll finally have an updated prescription for his glasses.

Outcome: I assisted him in providing a list of optometrists in his area several times due to always losing emails.

Health Plan: LA Care

“Securing Support”

LCM/CC/HN/RES/Nurse: Kathleen

Conditions: Parkinson’s Disease, Diabetes Type II, Asthma, Major Depressive Disorder, Anxiety, PTSD, Panic Disorder

Situation: My 60-year-old member is a senior who has recently been in an assisted living facility. They’re back home and require help around the house—they’re able to do daily activities on their own but would like extra help. My member had explained to me they only had 15 hours for IHSS and wanted more but hadn’t heard back from the IHSS case worker about an approval of more hours.

Outcome: I assisted my member by calling IHSS and inquiring about the status of more hours. I helped by leaving a message to their IHSS case worker so they can contact my member. Shortly after, my member received a call from the case worker. Few weeks later, my member received a letter in the mail confirming an increase in hours. We’re now working together to find them a caregiver.

Health Plan: Community Health Group

“Overcoming Harassment”

LCM/CC/HN/RES/Nurse: Christopher

Conditions: Diabetes

Situation: My 63-year-old member was on the verge of eviction and was being harassed by his landlord to the point of being taken to court.

Outcome: In a coordinated effort with his housing navigator at Jewish Family Services and also using Connect IE to find the legal resources we were able to find a local apartment building in Barstow. My member is now in his own more modern apartment and is very happy with the help he received from his care team.

Health Plan: Inland Empire, Health Plan

“A Guiding Hand”

LCM/CC/HN/RES/Nurse: Deanna

Conditions: Gastrointestinal Issues, Diabetes Type I, Asthma, Anxiety, Depression

Situation: My 60-year-old member had been trying to figure out how to navigate a few different assistance programs (the Low Income Home Energy Assistance Program and the Low Income and Disability Power Discount). Unfortunately, no one was able to help guide her or explain these resources available and she was truly struggling as she needed the help ASAP

Outcome: I was able to help her call the right places and help her through the application process and once the whole process was finished and I walked her through the process, she was able to get on the program and get the assistance she needed, even getting help with past bills. Her bill was reduced to under $100 and she was overwhelmed with joy. She’s now able to better manage her expenses and understands how to troubleshoot some problems with the programs if needed!

Health Plan: AmeriGroup

“Renewing Care”

LCM/CC/HN/RES/Nurse: Nancy

Conditions: Asthma, COPD, Hypertension

Situation: My 62-year-old member had trouble with Calfresh application and also had Medi-cal renewal issues.

Outcome: I met her in-person and assisted with the Calfresh application process, also confirming the required documentation for her Medi-cal renewal.

Health Plan: LA Care

“Justice Served”

LCM/CC/HN/RES/Nurse: Kevin

Conditions: Anxiety, COPD, Major Depression Disorder

Situation: My 61-year-old member was born in Indonesia and is unable to work due to a shoulder injury. She’s receiving income assistance through the General Relief program from the Department of Public Social Services (DPSS) of LA County but she reached out to me to inform me she did not receive her benefits for this month and felt anxious about calling the DPSS customer service line as she has a difficult time understanding other English speakers who speak at a fast pace. I supported her by calling DPSS together.

Outcome: Once connected with a representative from DPSS, we discovered that multiple unauthorized transactions were conducted using her benefits. During this call, I served as a mediator to simplify the process for her. She was able to file a theft report that will now go under investigation and she hopes that she can get her stolen benefits reimbursed. In the meantime, I have provided local resources for her to have access to food.

Health Plan: LA Care

“Follow-Up First”

LCM/CC/HN/RES/Nurse: Rebecca

Conditions: Diabetes Type II, Cirrhosis of Liver

Situation: During visit on 3/19, my 55-year-old member was reluctant to make a hospital follow-up appointment with her PCP because he assumed he wouldn’t be seen for months. I encouraged and advised him to make an appointment, then agreed to call the PCP office together.

Outcome: We called his PCP’s office and requested a hospital follow up appointment. The representative took down some information about his hospital stay due to bile duct obstruction, and made an appointment for 3/21 at 10:00 AM. I explained to him the importance of following up with his PCP after a hospital visit and encouraged him to review referrals and medications with PCP, also scheduling a reminder to be sent on 3/20. He confirmed he would go to this appointment, and understood how soon an appointment can be made if it is an ER or hospital follow up.

Health Plan: LA Care

“Successful Re-Engagement”

LCM/CC/HN/RES/Nurse: Eric

Conditions: Dyslipidemia, Hx of Cardiac Arrest, Hx of Prostate Cancer, Chronic Liver Disease, Asthma, Left Knee Pain

Situation: My 65-year-old member enrolled in the ECM program 09/14/2022, but has been periodically unresponsive. My member had not completed a Comprehensive Assessment nor a Care Management Plan in over a year and reported they were recommended to have surgery on their left knee, but is unsure who to contact or where to go. This member was re-assigned to me 2/14/2024.

Outcome: I’ve successfully re-engaged with my member since the warm hand-off was completed. We’ve met in-person to complete the Health Risk Assessment and Care Management Plan. I’ll continue to explain and educate my member on how to navigate the health system and will provide the contact information of the orthopedic specialist and help coordinate appointments for surgery.

Health Plan: Molina

“Worries to Wellness”

LCM/CC/HN/RES/Nurse: Jasmine

Conditions: Asthma, COPD, High Cholesterol, Osteoporosis, Autism, PTSD, ADHD

Situation: My 58-year-old member expressed concerns over sinusitis and potential COVID symptoms, wanting to have a COVID test done but being unable to find a location to administer the test. My member was without a PCP to order the test and locations did not have testing materials available. She had been self-testing negatively at home for approximately a week, but still wanted her symptoms addressed somehow.

Outcome: I helped her navigate finding testing at a local pharmacy, as it seemed most viable at the time. Ultimately, she called the nurse advice line through her insurance plan and I helped her with talking to them about how to get an antibiotic prescription for the suspected sinusitis. Upon follow up, the prescription seemed to be helping her symptoms and her concerns had subsided altogether.

Health Plan: Santa Clara Family Health Plan

Colorful illustrations of school supplies and the letters ABC

 “School Support”

LCM/CC/HN/RES/Nurse: Ashley

Conditions: Youth SED/CHR

Situation: My 5-year-old member was newly assigned this past week; his mother stated that she had a court appointment and was unable to talk until later that afternoon. When I tried to reach out to her, she was not answering, and it appeared as if she had blocked me. I started to feel nervous as I also noticed on member’s MIF that they are close to experiencing homelessness. I was not sure how else I could reach them.

Outcome: Thankfully, the mother reached out with a different number and was more than willing to meet with me. I was able to schedule an appointment for her to meet and discuss goals to help her get the supporthe needs in school.

Health Plan: Santa Clara Family Health Plan

“Dental Dilemma Solved”

LCM/CC/HN/RES/Nurse: Denise

Conditions: Diabetes Type II, Asthma, Hypertension, Depression, Worn knee and foot cartilage, Arthritis

Situation: My 52-year-old member needed an appointment with her dentist to get some fillings done and to get an authorization for a crown, but was interested in changing dental plans as she would like to return to the dentist she used to see. My member states she has an ACCESS Dental plan, and she is not sure how to change dentists.

Outcome: I called ACCESS Dental to ask how she would be able to change to her previous dentist. I was able to obtain information and was told with ACCESS Dental, she is assigned to one dentist and there are limited dentists for her to choose from. I asked how my member could choose a dentist of her liking and was told she would need to change her plan. I called Health Care Options with my member and was able to change her dental plan to Denti-Cal. Member was told she would get a welcome packet by mail, and will then be able to choose the dentist of her liking.
Health Plan: LA Care

“Navigating Emotions”

LCM/CC/HN/RES/Nurse: Karla

Conditions: Asthma

Situation: My 12-year-old member wants to talk to someone regarding how to navigate her feelings. Her mother wants a counselor or therapist for her daughter outside of school.

Outcome: I called Community Health Group services and asked for therapy for teens near my members area—I was helped and given two resources. I contacted both and asked for information, then forwarded it to my member’s mother. She made an appointment for her daughter after talking to both.

Health Plan: Community Health Group

“Utility Uplift”

LCM/CC/HN/RES/Nurse name: Karla

Conditions: Keratoconus—right eye, Cystitis unspecified without hematuria, recently gave birth

Situation: My 28-year-old member needed resources for utility assistance because her bills had been high and she couldn’t keep up.

Outcome: I sent her links for the care programs through Edison and Southwest gas. I also saw her in person on 3/20 and she stated she submitted the applications, and they approved her. They deducted a lot from her bill and it’s going to help her a lot. She thanked me for providing that information to her and is busy with her new baby!
Health Plan: Inland Empire, Health Plan

Care Management

ECM California Helpline
Tel: (310) 280-5203

Washington Health Homes
Tel: (206) 926-3890

Locations

Garden Grove
Tel: (714) 897-1071 | Fax: (714) 373-4696

Lakewood
Tel: (562) 925-7401 | Fax: ( 562) 925-8898

Downey
Tel: (562) 928-9700 | Fax: (562) 928 8300

Downtown Los Angeles
(Virtual visits only)
Tel: (213) 765-8123 | Fax: (213) 336-3032

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12566 Valley View Street
Garden Grove, CA 92845
Tel: (714) 897-1071

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