Success Stories

Mr. N and Elderplan FIDA Total Care

Mr. N, a 51 year old male, voluntarily enrolled in Elderplan FIDA Total Care on March 1, 2015. Prior to joining, he belonged to Elderplan/HomeFirst MLTC Plan from July 2014 to February 2015, and had Medicare Fee-For-Service benefits.

At the time of the enrollment, Mr. N had been hospitalized from February 27, 2015 to March 4, 2015, due to diabetic foot ulcers. He was discharged home with skilled nursing services through a CHHA with wound care three times a week. His medical history stated an abnormality of gait, anemia, GERD, vitamin deficiency, diabetes mellitus, diabetic foot ulcers to both feet, and toe amputation of the left foot.

Mr. N´s initial UAS-NY assessment was completed on March 10, 2015 and proved Mr. N to be alert and oriented, living alone in a one-bedroom apartment. His appointed guardian visited and provided financial assistance as needed. Upon enrollment into FIDA, he was approved for Personal Care Worker Services seven days a week, seven hours a day and recently had a PERS unit installed.

Prior to the first IDT meeting, Mr. N´s FIDA Care Manager assisted and coordinated care through continuous communication with a skilled RN and ordering wound care supplies. She also assisted in switching Mr. N from his existing Primary Care Physician (who was out of network) to a home-visiting Primary Care Physician for better coordination. In addition, the FIDA Coordinated Care Team approved 36 sessions of hyperbaric treatments for his diabetic foot ulcers.

The first successful IDT meeting was held on May 1, 2015, and included Mr. N, his Personal Care Worker, and Nurse Practitioner (NP). The previous PCP refused to participate in the IDT, thus causing a delay in scheduling. Mr. N´s diagnoses and medications were reviewed with the NP and necessary changes were identified and made.

Mr. N was checking his blood sugar every night regularly, and during the IDT meeting it was discovered that he was running out of test strips. The NP called in the new script into the pharmacy so he could obtain more test strips, and in a greater quantity, so that in order to check his blood sugar twice a day instead of once.

Mr. N continues to receive skilled services through CHHA. His nurse visits him three times a week for wound care, and he was approved for nine additional sessions of hyperbaric treatments, as clinical documentation showed progress.

Mr. N has had two additional IDT meetings since enrollment that addressed his current needs, covered services, coordination of benefits, wellness goals and safety in the community. Mr. N still visits his podiatrist every week to monitor the status of his wounds but hyperbaric treatments were completed as they healed. CHHA RN skilled services remain in place, three times a week and include education in regards to signs and symptoms of wound infection and diabetic care.

At the present time, Mr. N is satisfied with ElderPlan FIDA Total Care and remains compliant with his person-centered plan of care. This was a clinically complex case that required much coordination to help Mr. N achieve a higher level of wellness. The IDT continues to meet and work together to assure that Mr. N receives all necessary services so he may remain safe in his community.