Transforming the Patient Experience – Gloria’s Story

Gloria, a 72-year-old Medicare beneficiary, has lived in a small rural town in North Carolina her entire life. She loves the sense of community, bumping into friends, family, and past students wherever she goes. After dedicating years to teaching second grade at the local elementary school, she has finally retired and spends most of her time curled up with a good book or at the local community garden.

Since retiring, Gloria moved into a modest one-bedroom apartment to try and minimize her monthly expenses. Having lost her husband 10 years ago, Gloria must pinch every penny that comes her way. The meager pension she receives is barely enough to cover necessities and is a constant source of worry for her. Earlier this year, Gloria was diagnosed with a heart condition, diabetes, and depression, which requires regular doctor’s visits and expensive medications.

With her limited income, Gloria often must make difficult decisions. Groceries, rent, utility bills – everything must be carefully budgeted. The fear of having to choose between her health and basic needs is a heavy burden to bear. When Gloria’s beloved car — which faithfully served her for years — broke down, she found herself without transportation. The doctor’s office where she receives her primary care is over 20 minutes, and the specialist she needs to see for her heart condition is even farther.

At first, Gloria tried to rely on friends and neighbors for rides. They were more than willing to help, but their schedules didn’t always work with her appointments, and she didn’t want to become a burden. Gloria attempted to use public transportation, but the routes involved multiple transfers, making the journey time-consuming and too physically demanding for her. Desperate to find a solution, Gloria found a local non-profit online that offers transportation with the help of her daughter.

In May, Gloria was admitted to the hospital with severe chest pain and her medications were changed. When she tried to contact the transportation resource, she found they couldn’t offer her a ride to her follow-up appointment since the specialist is outside of county lines.

Luckily, Gloria was contacted by CHESS the day after she was released from the hospital, and CHESS was able to coordinate a ride with another resource that was allowed to transport across county lines. The only problem was that they only offered rides until 2PM, and Gloria’s appointment was at 3PM. CHESS contacted the provider’s office and changed the appointment on Gloria’s behalf so she could receive a ride.

During ongoing conversations with the CHESS Social Worker, Gloria also mentioned she was having trouble fulfilling her court mandated counseling since her counselor was not comfortable with home visits, and she had no way to get to his office 30-minutes away. CHESS helped Gloria find a local behavioral health provider close to her apartment, so she could walk to her weekly appointments.

With reliable transportation and consistent follow-up, Gloria’s health has improved significantly. She attends her regular counseling sessions and receives prescriptions and refills for the medications to manage her chronic conditions. CHESS helped her apply to Meals on Wheels and a medication assistance program, which has further eased her financial worries. Gloria has regained a sense of control over her well-being and is able to maintain her health and continue to do the things she loves in her small town.