Coordinated health care links Syracuse couple to valuable social services

September 10, 2019

A doctor’s referral for services usually doesn’t include fixing a leaky roof. But for Goshen Health patients Nancy and Richard Coy of Syracuse, the home repairs were some of the best medicine they have received this year.

Healthcare providers at Goshen Physicians Family Medicine Milford knew the couple needed help beyond primary care. That’s why they tapped into services at Indiana Lakes Accountable Care Organization (ACO).

“We look at the whole picture to help high risk patients balance conditions in the home that may affect their health,” explained Jacinda Garner, a licensed clinical social worker with the ACO.

For the Syracuse couple, that meant looking for solutions beyond traditional medicine. Garner saw a pattern when she dug into the couple’s medical history. A car accident, financial struggles, mobility limitations, sleepless nights and constant worry added up to a call for help.

Garner arranged a home visit by Serving Hands Ministries to assess the extent of repairs needed in the home. The faith-based non-profit brought together laborers from Nuway Construction and Granite Ridge Builders who donated time to reshingle the roof, repair walls and build a wheelchair ramp. An anonymous donor provided materials for the project.

“Our goal is to link patients with effective care inside and outside our clinics before they are in a health crisis,” said Larry Allen, MD, Goshen Health Chief Medical Executive and VP, Population Health.

Indiana Lakes ACO offers coordinated care for patients in a four-county area. Healthcare providers in the accountable care organization work closely with social workers like Garner to connect patients with services they need. Services range from scheduling doctor appointments and getting home medical equipment to providing telehealth systems and tracking patient care.

“We provide a valuable service for our community when we can help someone stay in their home where they are comfortable and safe,” said Garner.

Nancy Coy at her home in Syracuse with the new wheelchair ramp.