Triad HealthCare Network social worker Chrystal Land, left, meets with Bea Morris, right, at Favor and Faith Family Care Home in Burlington Tuesday, Nov. 24, 2015.
Bea Morris was just fine living on her own, although she was getting older.
PHOTO/ Sam Roberts/Times-News
Until one hot summer day when she was in her garden picking beans and her legs gave out.
“I could not get up to save my life,” she recalled. “I lay there for about two hours in the August sun.”
Help finally came, but that wasn’t the end of the falls for Morris, now 82. Over a two-month period, she fell four times.
On each occasion, she was taken by ambulance to the emergency room at ARMC. Those visits added up to thousands of dollars in medical bills, paid for through Medicaid.
But things have changed since then. Morris, of Burlington, doesn’t live alone anymore, and she hasn’t had any recent falls. She credits, in part, Triad HealthCare Network Care Management, a contingent of nurses and social workers who visit patients at home.
The goal: keep Medicare patients out of the emergency room through social work and preventive home care.
IN AN EFFORT TO lower health care costs, Cone Health, which owns Alamance Regional Medical Center, formed Triad HealthCare Network, a group of physicians from across the Triad who may or may not be affiliated with Cone. What they have in common, however, are patients that they treat, sharing information and practices among themselves to coordinate care for specific patients, such as Morris.
Cone Health said that from July 2012 to December 2013, Triad HealthCare Network, considered a Medicare Accountable Care Organization, saved Medicare almost $22 million. Cone officials say the Triad HealthCare Network Care Management program played an integral part in the savings.
The care management team, led by Rhonda Rumple, is made up of a geriatric nurse practitioner, registered nurse care managers, the hospital, a clinical pharmaceutical manager and licensed clinical social workers, such as Chrystal Land, whom Morris calls her “angel.”
The team focuses on people with chronic conditions who make multiple trips to the emergency room, or who have had trouble handling chronic diseases such as high blood pressure — like Morris — and diabetes.
Team members visit patients at their homes and advise them on their doctors’ instructions. They also provide transportation to medical appointments, and help reduce the cost of health care by eliminating unnecessary care.
Right now, 77 people in Alamance County are on the network’s “critical risk” list. That means that they have had two or more admissions to a hospital in the past year. The 77 had an average of 218 hospital admissions and 97 emergency room visits.
THE NETWORK SERVES around 64 people who agree to the visits, which are not required for patients in the network.
Land visits Morris periodically to check on her blood pressure and simply to talk.
Beyond that, when Land was referred to Morris, she discovered that Morris had attempted to find long-term home care that fit her needs and her budget. She was unsuccessful until Morris stepped in and found Favor and Faith Adult Care, a comfortable senior living home that actually feels like a home. Morris, guided by Land, recently moved into the home in Burlington and said that she couldn’t have found a better place.
“She came by and told me about this place,” Morris said of Land. “I didn’t know places like this existed. We followed her up here, and I thought, ‘This is it.’ Nobody likes to leave home; that’s the hardest thing anybody can do. But this is the next best thing to home.”