In July of 2018, Health Guardians began work with Tabitha, who was referred from New Orleans EMS and University Medical Center Emergency department for using the Emergency Room 15 times in six months with one hospitalization. Medical providers serving the homeless on the street found her inside of a tent with an IV picc in her arm, and she was dealing with an infection in her chest from a previous open-heart surgery. Tabitha was also managing additional chronic conditions, such as asthma, heart disease, high blood pressure, type II diabetes, and high cholesterol, which required ten different medications.
When Health Guardians initially made contact with Tabitha, she and her boyfriend, Ash, were keeping her insulin in an ice chest in their tent because it required refrigeration, and Ash was running to the store for more ice throughout the day as each batch would melt. Two CCANO Patient Navigators tracked the couple down to a public library and enrolled them in a patient-centered care plan.
In partnership with the Medical Director of Healthcare for the Homeless, Health Guardians staff scheduled a weekly primary care appointment for Tabitha after an initial visit. To stay informed about doctor’s appointments and in the event of an emergency, Health Guardians purchased a cell phone for the couple to continue consistent communication. Additionally, CCANO was able to link Tabitha to Aetna Medicaid insurance, pay the co-pays for her medications, and supply boxes of food to the couple when visiting their tent.
CCANO’s Patient Navigator at the Low-Barrier shelter secured Tabitha and Ash stays at the shelter. Their SNAP benefits began once permanent housing in New Orleans East was acquired through combined efforts with the Low Barrier Shelter and UNITY of Greater New Orleans. Health Guardians connected the couple to a disability lawyer for Social Security Income, bought work clothes for their job interviews, and worked with her primary care doctor to setup specialty appointments.
Currently, Tabitha continues to make her doctor’s appointments at UMC, and the couple is saving up to purchase a car while Health Guardians assists them with bus passes to get to and from appointments. CCANO staff still make monthly home visits to their apartment and looks forward to seeing sustained progression in the Tabitha’s overall wellbeing and health.