Case Studies
Explore real-life examples of how our services have made a difference. These case studies showcase the personalized support and comprehensive care solutions we provide, highlighting the positive impact on our clients’ lives. Discover how we help individuals and families navigate complex health and social issues, achieve their goals, and improve their overall well-being.
Case Study: Ms. Abram's Story
Ms. Abrams, a 56-year-old female, living in a shared apartment, grappled with substance abuse, particularly crack cocaine and alcohol (beer), while receiving SSI. She was also behind on her rent and Con Edison bill. Despite her financial struggles, she faced numerous health issues, including COPD, a history of heart attack, and diabetes, in addition to schizophrenia and depressive disorders. Medication adherence was a challenge for her, leading to frequent missed medical appointments. Concerned about her mother's well-being, Ms. Katherine sought assistance from Guide2Care, opting for the Essential Plan due to budget constraints.
The navigator devised a plan with Ms. Katherine, involving accompanying her to visits with Ms. Abrams to build rapport and understand her current state regarding drug and alcohol use. The primary goal was to provide unconditional support to facilitate healing. Over the next five months, the navigator met with Ms. Abrams and Ms. Katherine two to three times per week, engaging in conversations lasting 15 to 45 minutes. Through consistent visits, rapport gradually developed, allowing Ms. Abrams to open up about her fears and desire for change. After a hospitalization for a heart attack, the navigator coordinated her discharge and scheduled a follow-up appointment with a cardiologist. Recognizing the need for change during the appointment, Ms. Abrams requested assistance with scheduling medical appointments, arranging transportation, and joining NA meetings online. The navigator helped organize her medical appointments, reinstated her Medicaid transportation, and facilitated medication management with Ms. Katherine's assistance. They celebrated milestones in Ms. Abrams' sobriety and shared responsibilities for attending medical appointments, managing medications, and contributing to bills, fostering a supportive environment for her recovery journey.
Ms. Abrams achieved a significant milestone of two years of sobriety, actively participating in online NA meetings and successfully transitioning to a studio apartment. She now manages her medical appointments independently, pre-pours her medications, and takes responsibility for paying her bills. With her newfound stability, Ms. Abrams prioritizes nurturing her relationship with her daughter, enjoying outings together to movies, music events, and dinners. The navigator remains an integral part of Ms. Abrams' life as she continues to focus on improving her nutrition and values the support and guidance provided.
Shifting the Caregiver Narrative
We offer a supportive community and resources to caregivers who have long carried their responsibilities alone, providing them with the assistance and companionship. Through our platform, caregivers can find connection, guidance, and relief from the isolation they may have experienced, empowering them to face their challenges with renewed strength and resilience.
Case Study: Arthur's Story
Arthur, a 75-year-old male, has experienced a significant decline in his physical and mental health over the past month, requiring increased assistance with ADLs and IADLs. Despite this, his request for additional home care hours was denied by his MLTC plan. Arthur lives alone, and his daughter Patricia, who has her own health-related issues, has been his primary caregiver. His eyesight began to decline rapidly after May, leading to worsened anxiety and multiple hospitalizations due to his inability to perform basic tasks independently. In addition to his vision problems, Arthur suffers from chronic medical conditions such as rheumatoid arthritis, COPD, urinary incontinence, obesity, and gait difficulties, necessitating verbal cues and assistance for all ADLs and IADLs. Patricia has been overwhelmed and felt unsupported by her case manager at the MLTC, leaving her feeling like she was running in circles. Seeking help, she reached out to our navigator for assistance.
After discussing Arthur's situation and quality of life needs with Patricia, the navigator inquired about her self-care and caregiving efforts. The navigator then developed a plan and gathered medical documentation from Arthur's doctors, hospitalizations, and PT and OT providers to highlight his needs and recommendations.
Letters from Arthur's doctors indicate that his vision issues significantly impact his ability to ambulate and perform tasks. Physical therapists noted that he requires assistance with walking, getting in and out of bed or a chair, bathing, and supervision for feeding, dressing, toileting, and hygiene. He should not engage in meal preparation or house cleaning.
Occupational therapists reported that Arthur's vision deficits, combined with weakness, impaired balance, and coordination, make ADLs, transfers, and mobility difficult, increasing his fall risk. Using this documentation, a comprehensive letter was written and submitted to the MLTC Plan to support the request for 24-hour home care.
Mr. Arthur received a letter from his MLTC approving his request for 24-hour home care. Prior to this approval, he was hospitalized due to a fall and subsequently sent to a skilled nursing facility. During his stay, Arthur felt very comfortable, enjoying various activities and having access to nurses and staff. Patricia also felt reassured by the facility's care, knowing she had the option to bring him back home with 24-hour care. The decision for Arthur to remain at the facility was made based on his preferences and needs, providing Patricia with peace of mind and allowing her to focus on her own well-being.
Case Study: Isabella's Story
Ms. Isabella, a 35-year-old woman who had no prior health issues, faced a significant downturn in her ability to work after receiving her second COVID-19 vaccine dose in October 2021. Seeking help at the Emergency Room two weeks later, she reported various symptoms, including ringing in her ears, weakness, chest pain, shortness of breath, and right-side pain, along with a sensation of her body being on fire. Since then, she has been grappling with brain fog, persistent muscle spasms, mobility difficulties, and numbness in both her right and left upper extremities. Despite being diagnosed with chronic fatigue, vision decline, chronic pain, abnormal weight gain, and chronic headaches, Ms. Isabella finds herself confronting disability, the risk of homelessness, and nutritional challenges due to her inability to work. She has sought support to appeal for Social Security Disability Insurance (SSDI) after her initial paperwork was denied.
After completing the intake with Ms. Isabella, the following steps were taken before submitting documents for review to the Social Security Office:
1. Collected all medical documents post-COVID-19 vaccination, including doctor's observations, detailed medical reports, current treatments such as physical therapy, and ongoing tests like cognitive assessments.
2. Organized the paperwork in chronological order and documented her work history.
3. Prepared a Medical Source Statement of Ability to do Work-Related Activities under both medical and mental health categories.
4. Compiled all this information into a comprehensive medical summary report.
Then, the completed documentation was submitted to the Social Security Office for review. Following this, Ms. Isabella utilized the medical summary report to prepare for her interview and as a reference during the process.
Post-interview, Ms. Isabella received a letter confirming her approval for SSDI. The navigator continues to follow up with Ms. Isabella, providing ongoing support and assistance as needed throughout her journey.
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