by Ruth Perry MD

A few years ago I was involved in the case of David Doe (not his real name), a patient who was referred by the hospital emergency department (ED) to a care management team in a low-income urban community in New Jersey. David was a homeless man who’d been living in an emergency shelter for three years with insulin-dependent diabetes, blindness, and chronically low sodium levels. The team consisted of a nurse case manager, a social worker, and two community health workers. Through the intervention of the social worker, Medicaid was willing to pay for an assisted living to provide him shelter and receive care because he was unable to care for himself due to his blindness.

Because of David’s multiple disorders, his management was complicated and he fell into a cycle of bouncing between the ED and his assisted living facility. During one particularly difficult weekend, David was brought to the ED three times for low sodium. Only after the nurse case manager and I spoke to his treating physicians at the hospital and nursing home were we able to determine the cause of all his ailments and placed him on appropriate medication to treat his low sodium.

While in the assisted living facility, the care management team continued to work with him, arranging an appointment with an ophthalmologist who determined that his blindness was due to cataracts, which were corrected with surgery. With his vision restored and his medical conditions managed, John was able to find stable housing, was linked to primary care, and is currently living independently.

He had no further ED visits.

Here is an extraordinary case where the application of team-based chronic care management (CCM) was able not just to help a patient get healthy, but to take control of his life again. Additionally, David’s story also highlights the importance of the social determinants of health in overall health and wellbeing This case also highlights the importance of the social determinants of health and in particular, the importance of housing. In many cases, housing is medicine.

This is not an isolated incident; countless others have had their lives restored by using a team-based approach to look critically at the source of a patient’s ailments, instead of seeing only the symptoms.



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