By BETSY TAYLOR
Armanda White, 60, has congestive heart failure, gout and arthritis. White’s son, daughter and the grandkids assist with cooking, chores at her home and with getting White to her medical appointments, but she credits a team from KentuckyOne Health with helping her improve her ability to manage her chronic conditions. “I’m getting to the point where I can be the provider for my grandchildren, instead of them providing for me,” White said.
The KentuckyOne program, called Health Connections Initiative, fields a multidisciplinary team for home visits with recently hospitalized patients who have high medical needs, disjointed health care and high medical costs.
Each care team includes a registered nurse, a licensed practical nurse, a social worker and a community health worker. Team members work with patients for 90 days after enrollment, conducting home visits focused on medical and social services needs with a goal of improving patients’ self-care and linking patients to a medical home for the future coordination of their care. The team can help patients with basic needs related to housing, transportation, food insecurity or low literacy, according to information from Kentucky–One Health. Members of the team make as many visits as needed to help each individual meet his or her personal health care goals and overcome barriers to care.
The core team is employed by VNA Nazareth Home Care. KentuckyOne’s parent, Englewood, Colo.-based Catholic Health Initiatives, has a minority ownership in VNA Nazareth. Additional health professionals, including dieticians and substance abuse and mental health counselors, can take part in home visits, as needed.