Area Agency on Aging programs help keep Niles woman out of hospital, in her own home
By Alexandra Newman
If it weren’t for Region IV Area Agency on Aging (AAA) and community partners, Helen, 67, would likely be living in a nursing home.
But thanks to a dedicated team of social and community health workers, nurses, caregivers, medical assistants and a nurse practitioner that all come to her, she’s able to live independently in her home in Niles with her partner of 33 years.
“Area Agency on Aging has helped me get where I can walk more than I used to because I have people who are excited for me and encourage me to keep going and get better,” Helen said during a recent visit to her home.
Helen was diagnosed with multiple sclerosis (MS) about 10 years ago. With that came mobility challenges and other health problems. She’s fallen and broken her hip twice and has dislocated it two other times. She has a catheter that needs to be changed monthly, and a variety of other health issues that pop up here and there like urinary tract infections (UTIs).
“When I started taking care of Helen, I didn’t know what to do,” Jamie, Helen’s long-time partner and now care partner, said. “I had to learn all of this myself. And I’ve had a lot of nurses, care people and doctors show me the ropes and help, but it’s been stressful.”
Helen was born in Elkhart, Ind., and the two met over 40 years ago working together at the same job. They said, “the rest is history.” They’ve lived in a variety of places around the area and state but have been in their home in Niles for about 10 years, which they fixed up themselves a little bit at a time.
“It was many years of not eating out, no ordering pizza, no Diet Pepsi, but we’re still here,” Jamie said.
He said Helen getting on the MI Choice Waiver program in October 2023 changed everything for them.
During one of her hospital stays for her hip, a social worker referred her to Area Agency on Aging. Helen was soon evaluated and enrolled in the Waiver program, an alternative to nursing home care.
With such a high level of care needs, AAA staff helped get Helen back on Medicaid so she could start receiving the vital services she needed to remain in her home.
She started receiving home-delivered meals as well as health and wellness supplies regularly. In addition, an in-home caregiver is there to help for 3.5 hours a day, 7 days a week.
“I’m happy I’m able to be in my own home and that I’m not totally stuck in bed,” Helen said. “I’m able to use the walker and wheelchair to get out of bed and out to the living room. I’m happy I’m able to do that.”
Jamie said they practice walking every day when the caregiver is there.
“I wouldn’t be able to help her do that without having another person here,” he said. “Every time we walk her, she gets more stamina built up and the Waiver program pays for that caregiver to be here.”
Last year, Jamie heard about the Integrated Care at Home (ICAH) program through Area Agency on Aging which offers primary care, behavioral health counseling, nutrition counseling and chronic care management in the home of homebound individuals.
The program was perfect for Helen with her low mobility and high level of health needs.
“I called because it’s hard to get Helen to the doctor. They wanted her to come in anytime she bumped her toe. We also don’t have a car, so with Carri coming, we don’t have to get Helen onto the bus and into her appointments. We like the people who drive the bus, but it’s just a hassle, especially when the weather is bad in the winter,” Jamie said.
When Helen has a new health problem pop up, like a UTI, Jamie is able to call and get assistance from the ICAH team promptly, including the program’s nurse practitioner, Carri. Even on weekends or holidays.
“Carri always calls back. She will talk to me about it and call in the medicine. If I call my doctor, they want me to go to the Emergency Room or wait until Monday. That’s just harder to do with Helen,” Jamie said.
The goal of Integrated Care at Home is to keep their patients out of the hospital with remote patient monitoring and person-centered care plans. In Helen’s case, it’s been an all-hands-on deck approach and so far, it’s been very successful.
Her goals right now are to get a new type of catheter to improve her health; as well as get fitted for special shoes and a hip brace so she’s able to walk more with the walker and rely less on a wheelchair.
“I think without AAA sending the caregivers and nurse practitioner, Helen wouldn’t be where she is now,” Jamie said. “And without them and me, she’d probably be in a nursing home. We can’t thank you guys enough.”
For more information about MI Choice Waiver or Integrated Care at Home programs, call the Info-Line at 800-654-2810 or visit www.AreaAgencyonAging.org.
The Generations Column appears each week in The Herald-Palladium.