Commonwealth Care Alliance

Paul's Story

May 1, 2017

Posted by Commonwealth Care Alliance

Before he discovered Commonwealth Care Alliance One Care, Paul didn’t care if he lived or died. He was slowly killing himself, drinking more than 30 beers a day and making regular visits to the local hospital emergency department as his health deteriorated and his behavioral health issues grew more severe.
“I was falling apart,” said Paul, 52, who grew up in the Worcester and spent the last several years in an apartment house in a poverty-stricken section of the city where people would regularly come in and out to use drugs or drink with him on his front porch.

Paul spent most of his adult life between emergency departments, inpatient psychiatric institutions and a few periods of incarceration. Although he had health coverage through Medicaid, or MassHealth, and Medicare, Paul felt isolated without a “care team” that could help him manage his complex medical and behavioral health needs. He would avoid seeking care until his substance use and behavioral health needs became severe enough that he had to go to the local emergency room – more than 30 visits a year – often resulting in an inpatient psychiatric admission.

But Paul’s life changed four years ago when he was informed that his Medicaid enrollment was about to expire, and a primary care physician referred him to CCA for coverage. Within weeks, CCA caregivers had met with Paul at his home, conducted an assessment of his clinical and social needs and devised a coordinated care plan to help him regain his life.

The CCA team’s interdisciplinary plan involved behavioral health and substance abuse treatment, as well as a focus on his chronic medical needs, especially a worsening blood condition that was causing clots in his legs and making it difficult to walk. The best part, Paul said, was that the team that was set up for his care was working together, eliminating barriers that commonly exist in traditional models of care.

“I didn’t need to set up an appointment with one person over here, another person over there and deal with all the hassle that goes into that,” he said. “Instead I had all these people working together, coming to my home to check up on me and make sure I had what I needed.”

Even when Paul was initially resistant to following his CCA care plan, team members persisted in visiting his home to make sure he was taking his medications and following through on the individualized plan they created with him to help address his medical, behavioral health and substance use issues.

“They kept coming over, and after a while I realized they really cared about me,” he said. “It was incredible to me that they would care so much for me, even when I didn’t care that much about myself.”

Since then, Paul’s life has improved to the point that he has not had a drink or used drugs for more than a year, and he has not had to be hospitalized for over two years. He now lives in the home of a close friend in North Brookfield, where he receives regular visits from his CCA nurse practitioner, social worker and other members of the team.

“In many ways Paul really is a model example of what we are trying to achieve through this innovative model of care delivery,” said Shaun L’Esperance, a CCA nurse practitioner who has been caring for Paul for the past two years. “We aim to care for him as a whole person, and over time you can really see how this interdisciplinary team-based approach has been transformative for him.”

Paul said that before he was enrolled in CCA, he did not expect to survive another year. Now, he enjoys sitting in the back yard on warm afternoons playing his guitar, thinking about what’s possible for him. “I have hope now, thanks to CCA,” he said. “There are a lot of people who are in the same boat that I was, so this organization is desperately needed. They are life-savers.”
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