www.MatrixForMe.

com

NP Kathleen
The member, who spoke primarily Spanish, had been discharged to
home from the hospital to be cared for by her family. However, her
family, also primarily Spanish speakers, were managing their own
concerns. Her daughter and son-in-law both had back issues and were
caring for their special needs child.
The members multiple conditions were very complex, requiring close
monitoring and assistance with everything from administering
medications to eating.
She had a follow-up appointment with a vascular specialist scheduled
for the same day as my visit. While I was there, the office called to
reschedule the appointment due to an emergency. Her medication
related to that appointment would now run out nearly 10 days before
the rescheduled appointment.
The member also had upcoming appointments with an ophthalmologist
and retina specialist, but she wasnt really sure why. I called the
ophthalmologist and retina specialist to obtain information so I could
translate to the member. I also placed a call to her primary care
providers office and made the Nurse Practitioner there aware of the
whole situation.
The NP was very supportive. Arrangements were made to reassess the
member prior to her medication running out and the office would
advocate to have another vascular surgeon appointment scheduled.
I discussed with the NP the idea of a rehabilitation facility being a more
conducive setting for the member due to her very complex needs. The
idea was presented to the member and family, who agreed to think
about the option and discuss it further with their care team (Matrix, the
health plan and the members primary care provider office) the next
day.

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In a coordination of care by the team, within 48 hours the member was

placed in a rehabilitation facility to better address her needs.