Imagine being so sick that you visit the emergency room at least ten times or are admitted to a hospital at least four times within a single year. This extreme utilization, combined with at least two chronic health conditions, meets the eligibility requirements for PCIC’s intensive case management program. However, many of our clients far exceed these requirements.
Reflect on the moments in your life where you have used emergency services. Will I or my loved one be okay? How will we afford this? What are we supposed to do next? Now imagine experiencing that feeling monthly or even weekly. You may wonder, how does someone end up needing that much emergency care?
I have observed that for many PCIC clients, their medical emergencies arise from unmanaged chronic illness. Their medical care becomes reactive rather than proactive as seemingly simple diagnoses, like high blood pressure, develop into much more serious illnesses, like stroke, heart disease, or kidney damage.
Lack of preventative care arises from a dizzying tangle of factors – inability to access affordable care, lack of transportation, unstable housing, low health literacy, food insecurity, unsafe or unhealthy community environments – the list goes on and on.
Over the last decade, there has been an increased focus on how to mitigate the impact of social determinants on health outcomes. However, health inequities continue to persist. As a case manager, it can be incredibly frustrating to see how broader social inequalities can manifest as preventable medical issues. For example, many of our clients struggle to find affordable, fresh produce in their neighborhood. Maintaining a healthy diet becomes very challenging when you live in a food desert[1], and your only food options are convenience stores or fast-food restaurants. Our clients living in these food deserts are automatically at increased risk for weight-related health conditions, like high blood pressure, diabetes, heart disease, and obesity.
PCIC helps clients stabilize medical and social needs and build self-advocacy skills for sustained health. As a care coordinator, I help clients connect to outpatient care, organize medical transportation, connect to local housing agencies, understand how to manage chronic illness, access home health providers and nurses, and provide resources for healthy food sources. My work is guided by my clients' personal goals to create sustainable plans for long-term health and wellbeing.
[1] Harden, John. “Interactive: Do you live in one of Houston's many food deserts?: Data show supermarkets avoid low-income neighborhoods, flourish in wealthier areas.” Houston Chronicle, 15 Dec. 2015, http://www.houstonchronicle.com/houston/article/Houston-still-have-long-way-to-go-to-address-food-6689980.php
