"When I came into this program it was like, really, really, how can I say this, at a time I needed support. My closest family member is 1,500 miles away. I was going through something, and the next thing I know, these wonderful people show up on my doorstep, and it was like they were basically more than just a support group for me to gain and get my health together. They have been there for me, when I say, they have shared good positive tears, tears of joy…they have been there for me. I really appreciate it… This is what the outcome has been for me so far, and I know it’s going to get a lot better." says Trondail.
If you ask him, Mr. Trondail will admit that he was losing control of his health and his life. He had multiple illnesses that caused him to make plenty of visits to the Emergency Room –12 times in a year to be exact. He also had many obstacles blocking his way from improving his health: he did not have a job, transportation, or a cell-phone of his own, and he was homeless. However, he accepted help from our team, and it was immediately clear his dog, Striphe, played a huge role in his health and his life.
From Day 1, the intervention team knew that Mr. Trondail was unique. He was very outgoing and very ambitious, so why was he homeless and jobless? Why couldn’t he overcome his illness? As one of five children, where was his support system? Our team found out that the answer to every one of those questions was, Striphe.
Striphe, Mr. Trondail’s dog, was the only resemblance of a support system in Houston that kept Trondail motivated. His parents, siblings, and son were scattered all around the east side of the country leaving Mr. Trondail to rely on Striphe for happiness. He couldn’t overcome his illness because Striphe’s health was more important to him than his own. Mr. Trondail couldn’t keep Striphe with him in the hospital for Doctor’s visits therefore he wasn’t going to show because he wasn’t leaving his dog. The most surprising factor was that he was homeless and jobless because of Striphe. Most government assisted housing facilities don’t allow pets, so Trondail sacrificed the chance to get housing and a job.
Combine all of these factors and add them to a man with multiple complex illnesses, and it becomes clear why he visited the Emergency Room 12 times within a year. Another concerning issue lies in the fact that he went to multiple Emergency Rooms outside of his normal Health System. All networks are not connected which automatically caused communication between ER providers and his Primary Care Physician to be difficult (or even non-existent).
Also, treatment provided in the ER was ineffective because the physicians didn’t have the information they needed to fully understand his case. They are typically only able to give such complex patients temporary remedies and follow-up with appointments that are more in-depth, but follow-up wasn’t a possibility for Mr. Trondail. He had zero means of communication and no address to call home. He, like so many other High-Need, High-Cost patients, got lost in the shuffle of the system.
Our team has worked with him for several months and were able to arrange government assisted housing and cell-phone, and we established a pill box system to help him keep track of his medications. Most importantly they helped register Striphe as an Emotional Support Animal which allowed for a “snowball-effect” of positive change to invade Trondail’s circumstance, including the fact that his son finally gets to visit him in his new apartment.
Mr. Trondail made great accomplishments, but he was also was a great accomplishment for our team. His case truly taught us that the key to providing effective health care is focusing on our patient’s values and goals. Now we can share our vision with others. Imagine what the outcomes of future patients and providers could be once communication between hospitals and social service agencies is improved, or once follow-up appointments can be made in a timely manner –an issue that Trondail is still faced with.
We will continue to learn from our patients and build the solution with the help of our stakeholders and partners, but for now, we will celebrate Trondail’s success and the knowledge PCIC has gained from working with him.
