Compassionate care coordination improves care outcomes

A member’s care journey doesn’t end outside the walls of a hospital. Kayla Perno, a Home & Community Care Transitions care coordinator since January 2023, beautifully illustrates this point through one of her member interactions.

Kayla was conducting a comprehensive clinical review of a 60-year-old member who was hospitalized for multiple conditions. Purposeful and personal conversations revealed that the member’s primary goal was to return home to his wife as quickly as possible.

Before reaching this goal, Kayla had to remove two substantial obstacles. The member required extensive IV treatments and wound care, and he also lived in an apartment with stairs to the entrance — stairs that he couldn’t climb in his current condition.

Kayla knew the member was frustrated. He was told that his IV antibiotic treatment would necessitate a prolonged stay and his desire to return home to his wife felt more and more out of reach. The member didn’t feel like his desires were being considered and he felt overwhelmed by the reality of his situation.

“Our priority is to facilitate a safe discharge plan,” says Kayla. “With this member, his wishes were just not being heard, so it became my priority to truly listen, advocate on his behalf and find a solution."

"My goal is to always make sure the member is heard, uncover any barriers or concerns that they or their caregivers have and make sure that I do everything in my power to ensure their outcome is as successful as possible.”

Kayla quickly realized that, in addition to meeting his medical needs, she also needed to focus on getting the member back home to his wife as quickly and safely as possible. Her first step was to present his case, and his desire to return home, to his providers and care team, who then championed his cause.

Next, Kayla connected with local home infusion services that provided training to allow the member and his wife to self-administer IV treatments and personally perform wound care at home. Meanwhile, she encouraged the therapy team to focus on being able to walk up stairs, which was a physical barrier that was stopping him from being able to go home.

“Connecting the member, his family and providers was key to his success,” says Kayla. “It was important for the provider to better understand the member’s goals and for the member and his wife to clearly understand current medical needs and resources available to them.”

Through Kayla’s unwavering dedication, advocacy and compassionate care, the member was able to overcome seemingly insurmountable barriers to successfully discharge and complete his recovery in his apartment with his wife. “So often I find that members are unfamiliar with the options available to them," Kayla says.

She continues: "From access to community resources like transportation or meal services to additional care support or non-traditional types of care, such as in-home IV treatments, most members just don’t know what resources are out there and how to access them.."

Kayla adds, "That’s why I love my job and being able to connect members to the care and resources that they need.”

Kayla’s story serves as a testament to the incredible impact that care coordinators can have on the lives of those in their charge. It’s a reminder that beyond the clinical data and treatment plans, it’s the human touch, the empathy and the tireless advocacy that truly optimize member care.