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Timothy- Health Homes Program

Health Homes Program

You have three months to live” was all Timothy could remember from his call with the gastroenterologist.

Head in hands, he sat there wondering how intractable hiccups could have led to something so severe – something so life altering. What Timothy couldn’t remember, but was later notified of, was that his most recent gastroenterology appointment had revealed late-stage esophageal cancer and late-stage liver cancer – the latter with countless lesions. Shortly after the phone call, he was hospitalized due to weakness resulting from weight loss, needing a peg tube for feeding. As a complex patient with history of hypertension, congestive heart failure, and a recent heart attack, he felt overwhelmed by the compounding health issues. And with such devastating news and few resources, Timothy was not just running out of time, he was running out of options.

Concurrently, the Health Homes Program had conducted a systematic caseload review. Comprised of Dr. Sandhu, Rachelle “Robin” Grassmeier, RN, and two Care Coordinators, they agreed that Timothy was the right candidate for this program. During the review, Dr. Sandhu looked up from his computer, glanced at Robin, and asked her to officially add Timothy to the Health Homes Program caseload. He needed our help.

Robin Grassmeier, RN, reached out to Timothy immediately. She described our Health Homes Program and how we could assist. And after a few conversations and some wholehearted convincing, Timothy agreed to see an oncologist and begin chemo to treat the two different, but equally complicated, late-stage cancers. Although accepting treatment is part of the battle, what follows is another: learning to live with illness.

Following chemo treatment, Timothy was unable to sleep, often felt anxious, and was losing feeling in his feet. Thankfully, he called Robin. Within a week, Robin was able to provide Timothy a hospital bed downstairs. Because he was often too tired to climb the stairs after treatment and/or didn’t feel secure in his footing, he wasn’t always able to access areas of his home. Robin was also able to get Timothy access to other assistive devices, too. As for the anxiousness and foot numbness, Robin and her team were able to change his medication. Weeks later, he was walking confidently around the home, anxiety-free, and could feel the carpet beneath his feet.

When we enrolled Timothy into the Health Homes Program, he and Robin talked nearly every day. When asking Robin how it’s been working with Timothy, she said, “I’m a 17-year veteran trauma nurse and Timothy was able to teach me something new every day. He’s needed many things from me and this program and it’s been a pleasure learning from him. If it wasn’t for our Health Homes Program, he would have fallen through the cracks of our healthcare system.”

“If it wasn’t for our Health Homes Program, he would have fallen through the cracks of our healthcare system.”

-Robin Grassmeier, RN

To date, Timothy has been enrolled in our Health Homes Program for two years. Now, he does not dread phone calls with healthcare professionals. On the contrary, he prefers them. Having survived long after the three months he was promised by his gastroenterologist, Timothy is showing normal carcinoembryonic antigen (CEA) levels, signifying the cancer is under control. His most recent pet scan revealed the lesions on his liver have significantly decreased and his tumor has shrunk considerably. Timothy was recently notified by his oncologist that he may make a full recovery.

With the Health Homes Program and the Neighborhood employees that make it so, Timothy has a renewed sense of hope, health, and happiness. We are so grateful for our employees who make our patient’s health their priority and go above and beyond, regardless of situation or circumstance. Thank you for working to make the Health Homes Program vision a reality.