We used to work for (HMO) insurance companies. They would fax us cases to handle. When we received a fax, it meant that the insurance company was paying out "too much" money and they wanted something done about their problem ASAP.
Philippe had been transported to the E.R. six times in the last 3 months and he had been hospitalized for a total of 7 days. The HMO has to pay the ambulance company and the hospital costs. They were not happy campers.
Most seniors don't realize that when they join an HMO they give up their Medicare. Most seniors don't realize that HMO's are insurance companies that get paid to take care of them. The HMO bets it can provide complete healthcare for the senior at a cheaper rate than, so that then the US Government reimburses the HMO. Now you can figure out why it sometimes takes so long to get a referral to a specialist.
I visited Phiippe at his condominium. Upon entering there was a pathway from the door to the kitchen, and then to his favorite chair in the living room. On either side of the pathway was 3" of dust.
I'm not kidding.
By the chair in the living room, pill bottles were strewn all over the floor. The sheets on the bed were black. There were two months of dirty clothing lying on a bedroom chair and the clothing was equally black. Cockroaches were all over the condo. There was a container of milk, one package of donuts, and one package of hot dogs in the refrigerator.
Philippe had a girl friend, but she never entered the apartment. They always went out to eat.
He had family in Detroit, but they were estranged. Philippe had his monday night card buddies, but he stopped playing with them because he hated losing all the time. His girlfriend bought him the food in the fridge. Philippe had a car, but he could no longer see ahd he wouldn't get behind the wheel. His card buddies called every once in a while to check on him.
Remember I told you that there were social work solutions to clinical problems?
This is a prime example. Not only couldn't Philippe remember if he took his pills, if he dropped the pills, he couldn't find them. He had lost 90% of his vision and he could barely read the names or the instructions. He had no one to help, and he was afraid to ask anyone for fear he would lose his independence. The HMO was not at fault. They were treating him properly. He was just physically unable to comply.
It took as little as four telephone calls to arrange for Philippe to continue to live safely in his own condo. It only takes nominal funding and a Care Manager to make the arrangements. I can't tell you what became of Philippe. I made him safe. I brought him back into compliance with the HMO's directives and I was done.
Ronnee
For more information contact Senior Solutions at (954) 456-8984 or toll free at 1-800-213-3524
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