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Providing Support for Clinically Complex Clients

woman in wheelchair holding her caregiver's hand

Health Home clients are among the most clinically complex and vulnerable individuals that Aging, and Disability Services (ADS) serves. Health Home (not to be confused with home health) program care coordinators provide close coordination between primary and behavioral health services, transitional support, health promotion services, and community resource referrals for clients and family members.

The November 2020 issue of AgeWise King County carried success stories from ADS Health Home care coordinators in an article by supervisor Heather Dagg (read it here) and more become available every week. The stories help illustrate the expertise of ADS staff who work with clinically complex clients. We remove names and other identifying information to protect privacy.

Providing a wide range of services and supports

In March, Health Home Care coordinator Sharon Young shared five success stories that illustrate a range of supports that clients may need and the difference her work makes in their lives: 

  • Client 1—a 74-year-old female—was diagnosed with arthritis, strokes, and mental health issues. Beyond that, for many years, her dream had been to move to Redmond to be closer to her family. With limited finances and little immediate support, she didn’t know how to make the move happen. Sharon helped her client complete applications and connect with agencies, organizations, and services she would need to fulfill her dream. The move took place in earlier this year. 
  • Client 2—a 79-year-old female—was diagnosed with stroke, diabetes, back and shoulder problems, and chronic pain. She also needed eyeglasses but held onto a vision prescription for several months because she could not afford them. Sharon connected her client to a community resource that covered the cost of lenses and frames, and her client can see clearly again. 
  • Client 3—a 58-year-old female—was diagnosed with chronic pain, fibromyalgia, anxiety disorder, and diabetes. She had recently changed her primary care provider, and really liked her new provider. Then she began receiving bills for her appointments. This went on for three months, despite her attempts to resolve the matter, causing her stress and anxiety to the point that she found it hard to function. The client’s biggest fear was that she would not only be forced to pay the bills but also required to switch doctors again. Sharon helped her client contact the billing office in the correct department, update her insurance information, and clear her record. The client no longer receives medical bills, and her anxiety is gone. 
  • Client 4—a 79-year-old female—was diagnosed with recurring lung cancer during COVID. The client was under a great deal of physical, emotional, and financial stress. Sharon helped connect her client with PEARLS counseling services, which proved to be very helpful. Sharon also played a key role in helping her client connect with Cancer Lifeline, which helped relieve her financial burden and enabled her to purchase supplements to support overall health and a massager to reduce stress. 
  • Client 5—a 63-year-old male—was diagnosed with diabetes, chronic pain, and low vision. He and a friend who advocates on his behalf thanked Sharon for coaching him toward self-advocacy. Sharon helped her client speak up and get documents he needed for both prescriptions and financial assistance. As a result, he was able to join a gym and exercise to relieve pain. 

Meeting basic needs

Earlier this year, Care Coordinator Christy Narvaez had a 54-year-old client with osteoarthritis, diabetes, dwarfism, and a tracheostomy. His goal was to get new trach supplies because he lost supplies during a move between two suburban cities. Christy reached out to vendors, learned the process, called her client’s primary care provider, spoke with the nurse, requested chart notes to be faxed to the medical supply company, and asked the nurse to contact her client. He received his supplies the following week, thanks to Christy’s good work. 

Coordinating housing and care options

Around the same time, Care Coordinator Kate Kiser had a 72-year-old male client who was diagnosed with depression, unspecified psychosis, chronic kidney disease, congestive heart failure, and type 2 diabetes. He was admitted to a local hospital’s psychiatric unit under the Involuntary Treatment Act because of serious paranoia and delusions regarding the skilled nursing facility that was caring for him. He refused to return to the skilled nursing facility following discharge.

The client’s goal was to live somewhere that he would feel completely safe. Kate provided continuous support for her client and helped coordinate re-assessment between the hospital and DSHS Aging and Long-Term Support Administration’s Home and Community Services (HCS) division so he could be placed at a new facility. The hospital social worker located an assisted living facility in another county that was willing to accept the client, who agreed to move there after discharge

Kate assisted with move coordination by making a Washington Roads to Community Living referral so movers could be hired to transport his belongings. Unfortunately, the skilled nursing facility where the client had previously lived had thrown out his belongings after 30 days, including his wallet and clothing. Kate visited the facility to pick up his only remaining item—binoculars—and dropped them off at the hospital. After Kate also called a previous residence to determine that all his belongings were officially lost, she located $150 in Target gift cards to help him purchase personal items, and she advocated on his behalf to the HCS social worker to include purchase of new clothing into his Washington Roads goals. The client was successful in moving to his new home, with clothing and personal items, thanks to Kate’s good work. 

Ending life on her own terms

Recently, Health Home Care Coordinators Kim Wooding and Christy Narvaez shared a story about a client’s greatest wish that came true:

Their client—an 81-year-old woman born in Peru—was diagnosed with advanced kidney disease and diabetes. She was on dialysis and had a foot wound that medical providers suggested was cause for amputation. Her situation was grave. The client declined amputation and wanted to focus on end-of-life planning. She wanted to explore alternative medical treatment—hot spring therapy—in an environment that comforted her—Peru.

The client’s daughter opposed her mother’s plan and requested Kim’s intervention. Kim requested bilingual communication support from Christy. Using Motivational Interviewing techniques and a client-centered approach, they listened to the client’s point of view and her understanding of the risks and benefits of leaving the country, and they supported her plan. Kim and Christy spoke with the client’s son, who was prepared to accompany his mother back to Peru. They collaborated with Adult Protective Services, providing a full report of the situation, including client choice.

The client flew back to Peru, where her son connected her with dialysis services. She attempted healing through hot springs. We understand that the client passed away on her own terms in Peru— happy to have returned to her homeland.

Accessing long-term services and supports

Community Living Connections logo

To access long-term care services and supports in Seattle-King County, contact Community Living Connections (toll-free 844-348-5464). Information and resource referrals are professional, confidential, and free of charge.

For more information on the Health Home program or to refer clients to the program, visit the Washington State Health Care Authority’s Health Home webpage.

To access long-term care services and supports in Seattle-King County, contact Community Living Connections (toll-free 844-348-5464). Community Living Connections supports Medicare enrollment for people aged 60 and older and provides access to a broad range of additional services and supports. Those under age 60 should contact the DSHS Home and Community Services office for King County at 206-341-7600.


Contributor Irene Stewart edits AgeWise King County on behalf of the ADS Advisory Council, manages communication for Aging and Disability Services, and serves on the Seattle Human Services Department’s External Affairs Team. Irene compiled these stories from ADS Health Home care coordinators over the past six months. She is in constant awe of ADS Case Management Program professionals, including those in the Health Home program.

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