November Success Stories

Highlighting some of the great work Titanium Healthcare Lead Care Managers, Care Coordinators, and Housing Navigators achieved in November 2023 for the California Enhanced Care Management Program, Community Supports Program, and Washington Health Homes.

“Warm winter clothes for homeless girl”

LCM/CC/HN/RES/Nurse: Nyovi

Conditions: Scoliosis, Homeless.

Situation: My member is a 6-year-old girl with scoliosis who had surgery to correct her spine a few months ago. Per the member’s guardian, none of the clothes the member had fit her due to the cast on her body. They needed clothing that would fit over the cast, and since winter was approaching it would be good to get some warmer clothes for the season.

Outcome: I immediately called multiple organizations to ask for resources for clothing. We were able to find a church that was offering both food pantry items and clothing for all ages. I quickly got in contact with the member’s guardian to offer the resource and give the address and time for the event. The member’s guardian was able to utilize the resources. She will not only have clothing, but additionally access to a food pantry. She thanked me for helping with the urgent situation and reducing some of her stress.

Health Plan: Central California Alliance for Health, CA

Titanium Healthcare illustration of a winter jacket, scarf and sweater

“Providing extra support”

LCM/CC/HN/RES/Nurse: Denise

Conditions: Hypertension, Chronic Obstructive Pulmonary Disease, Arthritis, hearing loss, High Cholesterol, Stage 4 Lung and Brain Cancer.

Situation: My 59-year-old member has stage 4 lung and brain cancer and has been recently in and out of the hospital. The member has experienced a deterioration of his health and his current support system. His caregiver informed me that they are having a very difficult time navigating his MediCal appointments and healthcare needs. His wife expressed that she herself has learning disabilities and health conditions that affect her ability to do certain tasks. I offered to assist the member in all that was needed medically as well as with transportation.

Outcome: I was able to meet with the member in-person and assist with completing a medically tailored meals application and helped fill out an IHSS application form so that both the member and the caregiver could have extra support. I have also been coordinating with member’s hospital social worker to ensure all of member’s needs are met.

Health Plan: LA Care, CA

A Titanium Healthcare cute illustration of the Tooth Fairy.

“Not too late for the tooth fairy to visit””

LCM/CC/HN/RES/Nurse: Cristina

Conditions: Developmental Delay Trisomy, 21 seizures, Thyroid issues.

Situation: My pediatric member had never seen a dentist. When we met in-person meeting I noticed that the child’s teeth were in bad condition and asked the mother if he had seen a dentist or if he was under the care of a dentist. The mother stated he was not.

Outcome: We set a goal to find the member a dentist and I scheduled an appointment with Central Coast Pediatric Dental group which specializes in dental care for children with special needs. I called the member’s mother and she was very grateful for the service I provided.

Health Plan: Central California Alliance for Health

“Seeing the benefits of therapy”

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

Conditions: High Blood Pressure, High Cholesterol, Anxiety, Diabetes, Hemorrhoids.

Situation: My member is 43-years old. I assisted my member in contacting her PCP for mental health services as she recently lost her mother.

Outcome: I spoke with her this month and she confirmed she was now receiving mental health services through her clinic. She added that she speaks to her therapist every two weeks and sees the benefits already! She thanked me sincerely for all the help Titanium had provided.

Health Plan: LA Care, CA

“Finding a much needed Night Nurse”

LCM/CC/HN/RES/Nurse: Ana

Conditions: Respiratory Infectious Disease, Cornelia De Lange Syndrome, Developmental Delay, Trach and G-tube Dependent, Tracheitis, Cleft Palate, Nearsighted, Astigmatism.

Situation: My member is a 5-year-old boy. His mother, was very distraught due to Maxima care not having a night nurse available to help with her son. The member’s mother was contemplating paying someone out of pocket to help.

Outcome: I called Maxima Care on behalf of the member and mother and spoke to the nurse manager. We were able to get a temporary nurse to help out with the night shift. The nurse manager offered some overtime to the nurses on duty with my member until a new nurse was hired. The member’s mother called me sharing how happy and thankful she and family were for my help. The member’s mother stated “If you had not called Maxima Care and advocated for my son, we would have not had the help and care we so desperately needed. Thank you!”

Health Plan: Central California Alliance for Health

“Food bank resources”

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

Conditions: Tachycardia, Diabetes, Hypertension, Arrhythmias.

Situation: I was conducting a Comp Assessment with my 65-year-old member and the member expressed they sometimes run out of money to pay for food.

Outcome: I was able to locate 3 different food bank resources for them within her community. The member was very thankful for my help!

Health Plan: LA Care, CA

Titanium Healthcare illustration of a box full of food to represent a food bank.

“No longer homeless after four years“

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

Situation: My member is a 47-year-old female who has struggled with homelessness for four years. She had been sleeping in her storage unit. Last month, she was informed that she could no longer sleep there. She had nowhere to go and began to have suicidal thoughts. The behavioral health care manager (BHCM) assessed her mental health to ensure she was not a danger to herself and provided emotional support and suicide prevention resources. She also suffers from untreated multiple sclerosis. She walked an intense amount as she looked for a place to sleep and ended up going to the hospital for pain and fatigue from the MS. She was an inpatient for two weeks. The hospital struggled to discharge her to an assisted living facility. BHCM assisted the hospital staff in finding a facility.

Outcome: I offered her emotional support as she adjusted to a different environment. I motivated her to stay in the facility despite the strict rules. Today she stays in the home of a friend she met at the facility. She repeatedly thanks me for supporting and advocating for her. She is now motivated to see a neurologist to help manage her MS and is interested in looking for a remote job.

Health Plan: Inland Empire Health Plan, CA

Titanium Healthcare illustration of apartments and a house clustered together.

“Helping overwhelmed member”

LCM/CC/HN/RES/Nurse: Sandra

Conditions: Asthma, Congestive Heart Failure, Arthritis, Anxiety, Depression, Hypertension.

Situation: The member came to me and asked me to provide her with the forms from the office so she could fill them out and email them to the representative. I called the office to follow up and they mentioned the pictures of the new patient forms were blurry and they requested it either mailed or resent via email. I then tried to contact the member for two weeks to ensure she had mailed them out in order to get her first appointment scheduled (she was not responding). I was eventually able to get in contact with her and when I did, the member expressed her mental health had not been good and she felt “very sad” which is why she was unresponsive and why she had not re-sent the forms. She began to cry and it sounded like she was going to have an anxiety attack.
While on the call, I started to ask questions to ground her and distract her from the attack. The member was in a retail store while on the phone with me and I advised her to go back to her car and she was able to calm down while I helped distract her from the anxious feelings. I then offered to meet her in person after the call to offer my support. Member agreed and we met a local Starbucks where I resent the forms via email and confirmed with the representative that they had sent.

Outcome: The member was able to tell me more of her needs and thanked me for meeting with her and showing her she was not alone. I then encouraged her to call her psychiatrist and she met with her the following business day where she told me she was feeling much better and “less overwhelmed with her medical needs.”

Health Plan: Health Net, CA

“Referral for therapy”

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

Conditions: Diabetes, Hypertension, PTSD, Schizophrenia, Memory Loss, Arthritis, Vision Loss (right eye), Anxiety, Chronic Pain, Traumatic Brain Injury.

Situation: My member is a 56-year-old female with Diabetes, Hypertension, PTSD, Schizophrenia, Memory loss, Arthritis, Vision loss, Anxiety, Chronic Pain, Traumatic Brain Injury. The member expressed feeling very anxious, no longer speaking with the housing manager, having no one to speak to, and experiencing feeling like she was being stalked. I asked the member if she would be open to speaking with a therapist to help her learn to manage some of her stress and anxiety.

Outcome: I contacted LA Care and was able to obtain a referral for Long Beach Mental Health Center. The member was contacted directly by the center and began services. She has been attending therapy once a week and is very happy about her therapist.

Health Plan: LA Care, CA

Illustration of a Titanium Care coordinator holding a clip board and offering advice

“Finding the right therapist”

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

Conditions: Arthritis/chronic pain, Congestive Heart Failure, High cholesterol, Hypertension, Kidney disease, Lupus; MDD, ADHD.

Situation: My member is 32-years old. At the time of the Comprehensive Assessment update she had a PHQ-9 score of 22 and was not getting behavioral health support. My member reported a lack of a social support system and her diagnosis of lupus. In addition, her mental health conditions made it challenging for her to find support.

Outcome: The member and I worked hard to find a therapist, despite being met with numerous challenges. Many providers listed on the health plan portals do not actually accept MediCal or other limitations to scheduling an appointment (i.e., lengthy waiting lists, not accepting new patients, etc.) Through teamwork and diligence, I managed to link the member to a provider whom she has a good rapport with and is having weekly therapy sessions.

Health Plan: LA Care, CA

“Gentle encouragement to seek help for depressed member”

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

Conditions: HIV Risk, Hypertensive with Heart Failure, GERD, PTSD

Situation: My member had been diagnosed with depression, and anxiety. She currently lives with her mother as she is not working. The member states that she sometimes finds it difficult to get out of bed due to the severity of her depression and anxiety. She also expresses her hesitation to seek medical treatment or take medication. The member further claims to hear voices and sense people’s energy, so the member prefers not to take medications.

Outcome: I have spoken to the member to encourage her to visit her PCP and other specialists. After speaking with me, the member is now seeking assistance from a psychologist and another specialist.
Health Plan: Aetna, CA

“Helping homeless member to focus on her recovery”

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

Situation: My member is a 61-year-old female who lives in her car. She cannot work because she suffers from back and neck pain and recently had surgery. Her only income was $220 a month in General Relief benefits.

Outcome: I helped her call the Social Security Administration to ask what benefits she is eligible for. She set up a telephone appointment in May 2023 to start the process of applying for SSI. As the months went by (during which time she was not being called back), she went through a surgical procedure and had to recover at a skilled nursing facility for a short time. When she got out, she decided to go through the Health Advocates organization to follow up on her SSI case. As she started that process, she received a call from the Social Security Administration informing her of SSI case being approved. My member ended up not having to pay for help with her disability application, was paid back pay, and received her first check. When she got the first payment, she expressed that it felt like a huge weight was lifted off her shoulders. She began to feel hopeful about finding housing and was able to fix some issues with her car, which was not reliable anymore. My member is very grateful at the moment because she is able to focus on her recovery and not be stressed over her finances.

Health Plan: Health Net, CA

“Extracting a smile”

LCM/CC/HN/RES/Nurse: Daisy

Conditions: Asthma, Bipolar Disorder, Attention Deficit Disorder.

Situation: I helped my 46-year-old member with getting his dental hygiene checked out. The member contacted me in excruciating dental pain. I immediately contacted his dental office to set up an appointment for extractions.

Outcome: My member was successfully able to get his extractions done. Member is now getting proper dental help and is in the process of getting more, much needed dental work done.

Health Plan: Aetna, CA

Cute illustration of a dental hygienists leaning against a tooth and toothbrush.

“Road to recovery”

LCM/CC/HN/RES/Nurse: Giovani

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

Situation: My member is a 38-year-old male who has limited mobility in his shoulders as a consequence of his epilepsy. He stated that it causes him deep pain and that there is damage around the joint. He also has unaddressed anxiety and would like to speak to a mental health specialist.

Outcome: We created a plan to call his Primary Care Provider to address both of his needs and was able to schedule an appointment for next month to obtain a referral for an Orthopedic Specialist and a Mental health specialist respectively. This is the beginning of the member’s road to recovery and improvement – something that he has not been able to start for himself until now.

Health Plan: LA Care, CA

“Approved for CalFresh”

LCM/CC/HN/RES/Nurse: Nancy

Age: 61
Conditions: Hypertension, High Cholesterol, Major Depression Disorder, Diverticulitis, Diabetes.

Situation: My 61-year-old member was having trouble applying for CalFresh as she kept getting denied. I met the member in person and assisted them step-by-step with the online CalFresh application. I also assisted the member with uploading the required documentation online so the member wouldn’t have to mail in the required documents and wait for a response.

Outcome:  I completed the application process and was able to get the member approved for CalFresh. Member thanked me for the assistance and advised she would follow up once she has received any further documentation from CalFresh.

Health Plan: LA Care, CA

Cute illustration of a scale.

“22lb weight loss success!”

LCM/CC/HN/RES/Nurse: Nancy

Conditions: Pre-Diabetic, Thyroid Problems.

Situation: My 34-year-old member set a SMART goal of losing weight in 07/2023. Her starting weight was at 387 lbs. with a BMI of 58.84. She member stated that she working out three times a week. She also worked with her weight loss doctor focusing on counting calories, exercising and administering Saxenda shot.

Outcome: Outcome: As of 11/09/2023, the member reported current weight as 365 lbs. SMART goal has been achieved with a weight loss of 22 lbs!

Health Plan: LA Care, CA

“Changing PCP”

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

Situation: My member is a 20-year-old female who is not happy with her current PCP and has not attended an appointment with her doctor in many months. The member would prefer to change her PCP because she urgently needs a referral to a Gynecologist.

Outcome: Initially, I provided a list of doctors within the member’s area so the member could then select a provider she was interested in. Then, I assisted the member by calling Anthem to change her provider and we confirmed that changing her PCP would not affect the current services she is receiving at Children’s Hospital Los Angeles. The member was thankful for my assistance since this was a goal she wanted to complete for many months. Lastly, the member successfully scheduled an appointment with her new PCP. I will continue to follow up to see if she needs further assistance.

Health Plan: Anthem, CA

“Weight loss success”

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

Conditions: Bipolar Disorder, Major Depression Disorder, Arthritis, Memory Loss.

Situation: My member is a 62-year-old female who reports bipolar disorder, major depression disorder, and arthritis. She informed me that she wanted to improve her health by losing weight through incorporating physical activity and eating a cleaner diet. She continued to be dedicated to her health by incorporating daily exercise, by taking her dog on more frequent walks as well as cutting out unhealthy foods.

Outcome:  Member has lost a total of 20 pounds since May and states her health has drastically improved. She also states she will continue until she loses another 20-30 pounds. Member said is grateful to have me to help keep her accountable through SMART goal and progress check.

Health Plan: LA Care, CA

“Obtaining a new shower chair”

LCM/CC/HN/RES/Nurse: Maria

Conditions: Dementia and Hypertension.

Situation: Member is an 84-year-old Spanish speaking female only who has been diagnosed with dementia and hypertension. The member has a caregiver who is her daughter. The member had given verbal consent for me to speak with her caregiver. The caregiver informed me that her mother needed a new shower chair as she used it daily but the current one was in poor condition. The caregiver asked me for assistance with obtaining a referral to obtain a new shower chair.

Outcome: I contacted the member’s caregiver and informed her that the referral for the shower chair was approved, and the member would be receiving a new shower chair soon. I also provided the member’s caregiver with contact information of the medical equipment supplier office to schedule a pickup or delivery time and date. The caregiver thanked me for the support and assistance.

Health Plan: Health Net, CA

“Mom’s Meals for member”

LCM/CC/HN/RES/Nurse: Antone

Conditions: Anxiety, Depression, Post Traumatic Stress Disorder, Seizures, Vision Loss, Diabetes, Epilepsy.

Situation: My member is a 30-year-old female who has several medical health conditions including diabetes, for which she has an endocrinologist who addresses and manages her condition. She uses a Continuous Glucose monitor (CGM) to ensure her glucose levels are within normal range. In addition, she has expressed that she gained weight and would like to improve her health through exercise and diet. However, this has been challenging for her as she has lost her job and is currently taking courses for skills training.

Outcome:  I suggested Mom’s Meals services to her. She stated that she would be interested in trying them out. We completed the application outlining her diabetic needs. She has started receiving Mom’s Meals and she stated that she’s been feeling better about herself and has started to lose weight.

Health Plan: Health Net, CA

“A walker for grandma”

LCM/CC/HN/RES/Nurse: Kevin

Conditions: Arthritis, Hypertension, Diabetes, Chronic Kidney Disease.

Situation: My member is a grandmother who loves to spend time with her grandchildren. She expresses pride and joy when talking about her children. She is also entertained by going to watch movies with her family. Currently, she is attending dialysis treatment every Tuesday, Thursday, and Saturday. During our most recent comprehensive assessment, she and I identified that she needed a walker. She expressed that she had communicated her need to her primary care physician but had not received any follow-up on the request. Additionally, we discovered that she might be at risk of contracting shingles as she had not received her vaccine. She and I spoke about having all the tools necessary to be healthy enough to be able to do the things that she enjoys and spend time with her loved ones.

Outcome: I proposed to her that a primary care appointment could be scheduled to discuss concerns. She attended her appointment and voiced her concerns with her provider. I then followed up with the primary care office on referral for walker. I also helped her schedule an appointment at her local pharmacy to receive her first dose of shingles vaccine. She now has her walker and has received her vaccine. Now, she can focus on doing the things that bring joy in her life.

Health Plan: LA Care, CA

Cute Titanium Healthcare illustration of an older woman with a walker.

“Finding food close to home”

LCM/CC/HN/RES/Nurse: Karla

Conditions: Heart problems (heart attack, chest pain), High cholesterol, Hypertension.

Situation: My 54-year-old member is currently only working part-time and lives on his own. He has no help from family and is not receiving any benefits. I provided him with food resources and he was able to utilize them.

Outcome: My member was very happy with the new food resources as they were close to his home.

Health Plan: Anthem CA

“Housing help”

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

Situation: My member is 41-year-old women who is at risk of becoming homeless. My member currently lives in a Village home through her work. Unfortunately, she has reached the end of her contract and will need to move out soon. I mentioned to the member that it is amazing that she is part of the ECM program, as we are here for our patients who are experiencing tough moments. I explained to her how the program works and all the great resources we provide for our members.

Outcome: She went ahead and gave me consent to receive assistance in finding a home. I began to research homes in the member’s income range that also met the member’s requirements. I was able to provide her with 3 to 5 housing links and place her on a waiting list for apartments. She was so happy to receive the news, that we were able to get somewhere, as she felt stuck. She thanked me and stated she felt thankful for the help and assistance I provided.

Health Plan: Central California Alliance for Health, CA

“No more missed appointments”

LCM/CC/HN/RES/Nurse: Suzanne

Conditions: Type II Diabetes, Cirrhosis of the Liver,Cancer, Hernia.

Situation: When my 60-year old member did not feel confident to drive himself to his doctor’s appointments, he would miss or reschedule and wait until his son or a friend could transport him.

Outcome: I introduced the member to Central California Alliance for Health’s transportation services. Since this member has been utilizing these transportation services, he has not missed any appointment! He is so confident in using these services that he will contact me to schedule the transportation to his destination then calls me to schedule his pickup to return back after his appointment is complete! He also reports that the transportation services are there to pick him up within minutes.

Health Plan: Central California Alliance for Health, CA

A nice illustration of a woman looking at a bus schedule so she can get to her appointment  on time.

“Mold free housing for member”

LCM/CC/HN/RES/Nurse: Joan

Conditions: Bronchiectasis, Asthma, COPD, Rheumatoid Arthritis.

Situation: My member is 51-years old. His family noticed black mold in their Section 8 housing, but they could not get hold of their housing case manager. The member, who has respitory issues had lived with mold in the past and during that time had to use his nebulizer once a week. Now he was using it multiple times a day.

Outcome: We immediately reached out to the housing authority and obtained a Reasonable Accommodation move voucher. He is now in a new place, free of mold!

Health Plan: Central California Alliance for Health, CA

“ABA services for Autistic member”

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

Situation: I have been working to accomplish goals for my ECM member who is a 12-year-old boy with autism. My member’s parents have had a difficult time finding a behavioral specialist who is able to meet their needs. The parents are motivated to find ABA services to help with child’s behavior and medication management.

Outcome: I assisted the family by gathering a list of ABA services that accept Central California Alliance for Health. The parents and I were able to work together to navigate the CCAH website and identify available providers in the network. I will continue to offer support as we finds the right fit for their son.

Health Plan: Central California Alliance for Health, CA

“Transportation was the first step”

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

Conditions: Asthma.

Situation: My member is a 40-year-old female who has recently enrolled in ECM. My first encounter with her was very brief. She seemed very protective of any information she would release.

Outcome: As I made small encounters with her over the month, she seemed more willing to speak with me. She mentioned to me her last appointment with her primary care doctor was about three years ago. She explained she has trouble with attending appointments due to transportation. I explained to her that LA Care offers transportation to and from appointments. I was able to assist her with scheduling her appointment and scheduling transportation. She is still hesitant to take actions that will help improve her health but scheduling this appointment has already motivated her to continue taking actions that will help with her health.

Health Plan: LA Care, CA

“A new PCP”

LCM/CC/HN/RES/Nurse name Karla

My member is a 52-year-old female. The member had been unresponsive for more than a month and I was finally able to make contact with them and conduct all the assessments. The member expressed to me that she was not happy with her current PCP.

Outcome: Outcome: I was able to help her contact IEHP to get the PCP changed and also scheduled her first appointment. She was very happy and looking forward to her appointment.

Health Plan: Inland Empire Health Plan, CA

“Easing dental anxiety”

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

Conditions: Asthma, Glaucoma, Arthritis, Anxiety, Gastric Problems, Periodontal disease.

Situation: My 63-year-old member suffers from extreme anxiety, especially surrounding medical problems, and has been unable to secure a dental provider she both likes and trusts, as well as secure a place in their practice for treatment.

Outcome: I was able to find the member a new dental provider, schedule an appointment for initial evaluation, and attend an appointment with the member to better understand not only her demeanor with practitioners to rectify this problem for future visits, but also better understand her problems and the best course of treatment.

The member and I were able to ask all questions needed, allowing for a full understanding of all care plans. I was able to assist the member in implementing treatment plan, as well as explaining step-by-step instructions, in order to calm member’s anxiety and allow for treatment to be completed.

Health Plan: Anthem, CA

“Translating for my member”

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

Conditions: Arthritis, Diabetes, High Cholesterol, Hypertension, Depression, Chest pain.

Situation: My member is a 66-year-old who only speaks Spanish. She informed me that she was having trouble scheduling appointments with her Cardiologist and Gastroenterologist because no one in the clinics either answered the phone or spoke Spanish. She stated she had been trying to schedule these appointments for days but was unable to and she did not have anyone to assist her at home.

Outcome: I offered to call the clinics until they answered and she was able to get scheduled. I tried calling multiple times and was finally able to assist the member in scheduling her cardiologist gastroenterologist appointments. I sent the member a text with the date, time, and address of the appointments. Member thanked me for the assistance.

Health Plan: LA Care, CA

Illustration of a cardboard box with clothes inside for Titanium Healthcare.

“Food and warm clothes”

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

Situation: My member had recently regained custody of her son and needed help obtaining and filling out important paperwork to get her son enrolled in school. While the Community Health Worker was visiting the member and assisting the member, he noticed that the family did not have food in their RV trailer and that the member’s son did not have winter clothes.

Outcome: The CHW was able to make a call to St. Vincent De Paul and obtained an emergency care kit of food, warm clothes for the member and her son, and toiletries. The CHW will continue to be of support and provide local resources for the member.

Health Plan: Inland Empire Health Plan, CA

“Assisting with Social Security”

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

Conditions: Coronary Artery Disease, Diabetes,, Hypertension, Arthritis/Chronic Pain, Depression, Anxiety, Hearing loss, Low Cholesterol, Physical disability, Stroke.

Situation: My member is a 61-year-old who needed assistance with the CAPI program. My member did not qualify for SSI since she did not have the necessary points.

Outcome: I accompanied the member to the Social Security office to speak to a representative and to translate. I informed the Social Security representative that the CAPI program was requesting a ‘denial letter’ from the Social Security Administration. They wanted to know the reason why she did not qualify for SSI. The Social Security representative indicated that for the member to qualify for the CAPI program she needed this denial letter. The receptionist indicated that she had submitted the form, and that member would be receiving the denial letter by mail in a week. My member was very thankful that I escorted her and provided translation.

Health Plan: Health Net, CA

“Medically tailored meals”

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

Conditions: Hypertension, Anxiety, Major Depression Disorder.

Situation: My 40-year-old member only receives SSI which is set to expire soon due to not being able to re-certify that he is eligible for benefits. He is interested in receiving delivered medically tailored meals due to only being given little benefits in food stamps because of the SSI status.

Outcome: I recently put in a referral for the member to receive medically tailored meals. They were approved and started receiving their meals immediately. The member reached out to me and thanked me and stated the meals could not come at a better time seeing as his financial situation is becoming unstable and he needs this food to survive. I’m very happy that I was able to do this for the member.

Health Plan: Health Net, CA

“Finding a pediatric dentist closer to home”

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

Situation: My member is a 7-year-old child. The member’s mother was looking for a pediatric dentist closer to her home who accepted their insurance.

Outcome: After some searching, I found a dentist and called to verify that they accepted the member’s insurance, and forwarded the information to the member’s mother. The mother texted me shortly after to say thank you so much as she was able to make appointments not only for my member but for her other child as well.

Health Plan: Community Health Group, San Diego, CA

“A family home for the holidays”

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

Situation: I have been assisting this member in obtaining new housing in a safer environment for her and her children. The member has had housing through CalWorks and I have been able to assist in the process of researching vacant units, and connecting with the CalWorks coordinator, and landlords.

Outcome: My member’s goal was to be moved in before the holidays and was able to finally move into her new home with her children for the holidays.

Health Plan: LA Care, CA

“Steps towards better health”

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

Conditions: Hypertension, Substance Use Disorder.

Situation: This 38-year-old member had lost his job due to his car being towed from his apartment, and has been having financial difficulties. I had given information to member a few months ago suggesting going to Compton Mental Health Center where they accept walk-in patients and provide resources. Recently the member told me he was having a mental health slump and has started binge drinking.

Outcome: Member told me he was able to go to Compton Mental Health Center, walked in, and was able to get consultation with a mental health specialist. He stated he was able to receive more Social Services, received a gift cards for Target and Walmart and would be receiving a case manager. He plans to go once a week and although he is still consuming alcohol has reduced the amount, and said he feels is taking a step forward after making this appointment at Compton Mental Health Center. Member is now receiving Calfresh, unemployment, and is in CalWORKs. When I called Compton Mental Health the staff there kindly gave me member’s new therapist’s and appointment information, and will continue to communicate with member and therapist.

Health Plan: LA Care, CA

“CPAP language barrier”

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

Conditions: Chronic Kidney Disease, Chronic Liver Disease, Fatty liver, Sleep apnea, Osteoporosis, Cyst in Right Ovary, Hypertension, Anxiety, Asthma, Arthritis/Chronic Pain, Circulation problems, Pre-diabetic, Eye Cataract, Teeth Implant.

Situation: During an in person appointment with my 78-year-old member, she requested my help with scheduling medical appointments and obtaining status referrals on CPAP machine. She stated it was difficult for her to complete these tasks herself due to the language barrier. The member does not speak English. I was able to schedule members appointment to see an Orthopedic specialist. I was also able to get in contact with the staff from Apria Healthcare. The staff confirmed that the member’s order was ready. I was able to translate to the member the process of when her medical equipment would be sent and the steps of setting up the equipment.

Outcome: The member felt relieved that she obtained the good news on the CPAP machine. She also discussed with me that her Rheumatologist requested medical equipment, but she was unsure of the items. I was able to get in contact with Hanger Ort Pros Lakewood and spoke to them for further information on the referral. They were not sure what the referral was about. They stated the member should speak to her specialist and ask what the referral is. I was able to attend members appointment with her Rheumatologist on 11/28/2023 as per her request. I was able to assist with translation and obtain information regarding the referral the specialist had sent. The specialist stated he requested two knee braces. I will be assisting member with contacting Hanger Ort Pros Lakewood to discuss referral status. The member thanked me for all of her help!

Health Plan: LA Care, CA

“Closing the gaps in care”

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

Conditions: Depression, Kidney / Gynecological Issues, Hypertension.

Situation: My member is a 35-year-old who is homeless and lives in an RV that is stationed at a parking lot. Member was enrolled into the ECM Program mid-August 2023. Communication with her had not been frequent, as the member did not have a reliable method of communication. It was not until October 2023, that communication began to become more frequent as we agreed to hold in-person meetings. I learned that she had been hesitant to provide any information or connect with me, because she was not informed that she was going to be transitioned to Titanium Healthcare.

Outcome: As soon as I learned this, I made an effort to facilitate conversation between the former ECM Provider and the member. Fortunately, she was able to get clarification and an understanding of the transition. Simultaneously, I facilitated discussion between the PCP and the member. She had not seen the PCP in over 3 months due to lack of transportation and reliable communication. The 3rd week of November, I was able to schedule transportation for her to be seen by the physician. Following the appointment, the physician emailed me a list of care coordination needs for her. Working as a team, we have begun to address the member’s concerns and gaps in care. To address her housing status, a Community Supports referral has been submitted. Through this process, she has expressed trust and confidence in the care coordination that is being provided. She is now open and willing to complete assessments, now that she is addressing her health.

Health Plan: Molina, CA

“Christmas came early”

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

Situation: My member lives in a remote area of the San Bernardino Forest. He lives in a small brick studio which he rents from friends. He struggles with mobility and transportation. Helping him access his medical appointments by arranging his transportation is critical to his health. The team has been able to arrange his transportation to Phelan and Rancho to see his PCP and specialists.

Outcome: After building a strong rapport with him, he confided in me that he is dealing with food shortages and that he runs out of money to pay for food as most of his SSI goes to pay rent, bills, and alimony. After researching his local, but limited, resources we were able to find a St. Vincent De Paul food pantry in Phelan that contributes to the community with food, clothes, and hygiene items.

After building a bridge of communication with the local organizer, we were able to get the member’s food and even a Thanksgiving dinner! Due to his lack of transportation, the Community Health Worker was able to make the delivery of food, warm clothes, and toiletries to the member’s studio. When he received his care package he stated, “Christmas came early this year, this is the most food I’ve had in months!” We’re now working with him to assist with his CalFresh, IHSS, and additional resources. He hopes to use Community Supports to assist him with finding an affordable home in a less remote area. He stated, “I don’t want to live alone anymore, and I just want to live somewhere with paved streets so I can walk.”

Health Plan: Inland Empire Health Plan, CA

“It all worked out well in the end!”

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

Situation:My member was injured in a motorcycle accident and became unable to work. Due to the accident and waiting for SSDI to kick in, he became homeless. Luckily, he was able to find refuge in a local shelter. He has been working on his health and healing while taking odd jobs in the community. While out working just a few days before Thanksgiving he was late for curfew to his shelter and this violation caused him to be kicked out of the shelter.

Outcome: He was able to find shelter at an affordable motel and continue working his odd jobs. The Community Health Worker was able to provide him with multiple resources in the area for other shelters– specifically a resource for the Victor Valley Mission Thanksgiving Dinner. At that dinner he met someone who was volunteering at the event. They happened to be renting rooms at his halfway home. The member stated, “It all worked out really well and thanks to that dinner I’m now living in the nicest neighborhood I’ve ever lived in!” He went on to share that his old job reached back out to him and gave him an effective start date of 12/1/23. He stated, “Things are starting to turn around for me.”

Health Plan: Inland Empire Health Plan, CA

Care Management

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