Helping a Vulnerable Patient Stick with Her Care Plan—and Meal Plan

April 6, 2021

An Evolent Care Advisor closes a critical gap that could have prevented an isolated patient from getting enough nutrition.

Natalie Eudy, RN, a Care Advisor with Evolent Care Partners, was worried about “Carolyn.” A Medicare beneficiary with heart conditions, mental health issues and cancer, Carolyn lived alone with little family nearby, and she was not following up with one of her providers. There was also reason to fear she wasn’t getting enough nutrition.

Given her living situation and mobility issues, Carolyn needed a home health aide to help her get dressed, prepare meals and perform household tasks. The aide was available only for a short period each day, though, meaning that Carolyn was still responsible for many meals. Preparing those meals had become an especially challenging task now that Carolyn required a fully liquid diet after a procedure.

When Natalie reached out to Carolyn by phone, she was surprised to hear that Carolyn had signed up for a liquid meal delivery service but was not yet getting those meals. "The home health aide wasn't necessarily visiting long enough to help her blend food for the day," recalls Natalie. "It's likely that [Carolyn] would be missing meals with all that she had going on."

Natalie jumped into action, first calling the liquid nutrition program to understand why the patient was not receiving the meals. After discovering that the program had not received the necessary medical documentation, Natalie was able to quickly reach Carolyn's primary care provider, who participates in the Evolent Care Partners’ Medicare Shared Savings Program accountable care organization (ACO). Within the same day, the provider's office connected with the liquid nutrition program, ensuring that these vital deliveries would start for Carolyn.

Natalie helped the patient schedule her follow-up visit she had been avoiding. She also ensured that Carolyn had the necessary documentation in place to have home health aides visit for a longer time.

Care Advisors such as Natalie serve as an extension of providers in the ACO network, by building rapport with patients and overcoming barriers to managing their health. Ultimately, their work can also help prevent unplanned hospitalizations and ED visits.

"It's challenging and rewarding work. These Medicare patients have a lot of needs."

About The Heart of Care
Every day, members of Evolent's care management teams use their clinical expertise and problem-solving skills to help individuals overcome serious health challenges. The Heart of Care series tells stories from the field that highlight their dedication to patients.

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