Michele Koth is an RN in Ambulatory Case Management who is assigned as primary RN Case Manager for our HealthNet GMC population. This population is a disparate population whose health is greatly impacted by social determinants and poorly self-managed chronic disease. Michele performs telephonic outreach to these patients, conducts assessments to address urgent social care and clinical needs, and engages patients to establish health care goals. In a unique partnership with HealthNet, Michele is able to leverage community representatives from HealthNet to check in on patients at their homes.
In June 2020, Michele engaged a patient and through telephonic assessment determined the patient was very high risk. She telephonically assessed the 56-year-old lady, who had a history of anorexia nervosa, to be extremely frail, 41 pounds, without food, inability to shop for herself, little income, and did not have teeth to consume most foods. Michele engaged the support of the community representatives from HealthNet to coordinate the delivery of food, clothing, shoes, and blankets. Additionally, Michele coordinated additional services based on information shared by the community representatives after their arrival. She learned from the representatives that the patient was unable to shower herself, struggled to get up and downstairs to her bedroom, and had no DME in the home to assist her with daily living. In order to get around, she was using a single crutch, that was not sized appropriately, to keep her balance throughout the home and up and downstairs. Michele took action and facilitated orders for Home Health, PT, OT, a Social Worker, and a Long-Term Care Manager. Michele also assisted with the coordination of IHSS caregiver support to assist the patient with her daily living.
As of October 2020, the patient has received 8 weeks of home health support, PT, OT and now has an In-Home Support Services Caregiver who visits daily. She also receives food regularly, completes a set of daily exercises, and has the proper DME in the home for support when needed. I was contacted by one of the community representatives who stated in part:" I've been able to watch the transformation of an individual who was alone, doing the best she could to manage, to someone who is excited to take life head-on with the support of her extended family."
I'm not completely sure the patient would be where she is today without the support from Michele throughout this process. Her compassion and care for the patient were second to none, and to me, a role model for all. I feel fortunate we have someone like Michele in partnership, supporting our members each day.