Case Study: Care Coordination
The following case study illustrates a real example of Synergy Connect’s diversity
and impact. At identification, the member was homeless and dealing with multiple
complex medical, behavioral and social issues. Through Synergy Connect, our team
was able to align and maximize all available resources including:
locating the member, establishing a connection with a Care Coach
and successfully coordinating with our health plan client’s resources and member’s
provider to ensure the most effective care plan was in place. By organizing
the clinical approach, we were able to employ our specialized care coaching to help
John attain self management goals, including securing employment and proactively
controlling his diabetes.
John is a member of a Medicaid plan in the Northeast. In addition to having Diabetes
and Asthma, he also struggles with Depression and Bipolar Disorder which exacerbate
his condition. Socially, he has minimal familial support and often is homeless.
He is twenty years old, unmarried and unemployed.
John has had several bouts of diabetic ketoacidosis (DKA) that have caused him to
be hospitalized. He has been non-compliant with his depression medication and insulin
regimen and the stresses in his life increase the chances of having further DKA
episodes as well as other avoidable uses of the healthcare system.
Through the Synergy Connect Care Coordination process, referral mechanisms were
established between health plan Case Management and the Synergy program. After his
most recent hospitalization, John is referred to Synergy. A critical aspect of Synergy
Connect, Clinical Collaboration between Synergy clinical leadership and plan health
management not only review a member’s medical condition, but also drill deeply on
psychological or social challenges that a member may be facing. Through a review
of John’s case, it is determined that there were community based organizations that
would be helpful to him and that he would be well served to be working with a Synergy
clinician on a regular basis. It is also noted that John regularly frequented a
particular homeless shelter.
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