The Coverdell Stroke Coach Service Quality Improvement Pilot Project was a partnership between the Better Health Pathways HUB and The MetroHealth System to facilitate engagement of patient navigators / CHWs in the management of those at highest risk for stroke events, post-event discharge support, and follow-up of stroke patients across clinical and community settings. The pilot was part of the workplan for the Ohio Department of Health to meet the CDC strategy of the Ohio Coverdell Grant requirements. This story profiles how a CHW successfully worked with a client to meet their needs as part of this pilot project.
A client we will call Sam faced a life-altering event when he suffered a stroke and the beginning of a challenging journey for him and his family. A managed care plan referred Sam to the Coverdell Project, with a primary need for home support and medication management to address his diabetes; his glucose level was >300mg/dL. The Coverdell Project connected Sam with a CHW from the United Way of Greater Cleveland.
The CHW identified eight critical pathways to support him, including educating him about strokes, learning the power of social support, managing exercise and screen time, and understanding diabetes. His medical home was established with MetroHealth’s Department of Internal Medicine, where a CHW scheduled an appointment for medication reconciliation, and he was referred to specialty care in neurology. He also received social service support from the Case Western Reserve Ombudsman, who explained to Sam’s family that he must be issued an eviction or discharge notice before an appeal could be made. They advised the family to appeal the discharge, ensuring Sam would not be sent to a shelter. Sam was then referred to the Department of Senior and Adult Services (DSAS) for activities of daily living and the Ohio Home Care Waiver was reopened for his long-term care services.
The United Way team played a significant role in wrapping community social services around Sam including coordinating with MetroHealth to provide a registered nurse for his care. Sam’s journey included visits to the emergency department, rehabilitation, and ultimately long-term care. Throughout this period, he received essential medication management and support. Although Sam is not living independently, he is well cared for in a facility, and his family visits regularly. Without the intervention of the CHW and the Coverdell Project, as well as the collaborative efforts of The MetroHealth System and his family, Sam’s condition could have been fatal. The project was a success, providing much-needed stability and care for Sam and his family.