Delivering Care, Love, and Respect Every Day: Our MLTC Plan—and Our HHAs—in Action!

Although 79-year-old Luly* has dementia and is no longer able to be by herself, her days are full of love and caring, thanks to round-the-clock support provided by four dedicated Personal Care home health aides—Miriam Bonilla-Britto, Jissell Taveras Perez, Raisa Calero, and Marina Moreno De Del Orbe. 

Together, Miriam, Jissell, Raisa, and Marina work split shifts in perfect harmony. Like Luly, who is a member in our Medicaid Managed Long Term Care (MLTC) health plan, all four aides speak mainly Spanish, and the personal care services they provide are covered completely by her plan, which is designed for Medicaid recipients with an ongoing need for long-term care.

For the three-plus years that Luly has been an MLTC member, “she has never been to a hospital,” says Miriam proudly. When asked to recount the many activities they do each day, Miriam starts with: “Walk, walk, walk.” In nice weather, they go outside and look at flowers, which Luly loves. Miriam also makes sure there are flowers in the apartment—synthetic ones so Luly can touch and play with them—and dolls, which Luly also loves. In winter, the aides walk with Luly up and down the halls of the building.

Luly was born in Bolivia and moved to New York City in 1973, settling in Manhattan’s Washington Heights. In 2021, she enrolled in VNS Health’s MLTC health plan with her husband, Mario. Before he died last year, Mario told Miriam, “I know she’s going to be fine as long as she’s with you.”

Knowing that his mother is safe and happy in her home of 50 years is very important to Luly’s son, Junior, since he lives more than 200 miles away in Washington, DC. While he calls her every day, Junior is only able to visit Luly about once a month. When he’s not there, he rests easy knowing that Luly’s four VNS Health aides are attentive to her every need. Because Luly has dementia, they keep her activities of daily living to a strict schedule, down to planning when she should drink her next cup of water. They help Luly with dressing, showering, toileting, fall prevention and light housekeeping, and also manage her meals, make sure she takes her medications, and bring her to doctor’s appointments.

 “VNS Health has been an amazing help,” Junior says. “The aides really are our extended family.  They even do her nails and take her to a hair salon!”

Luly’s support team includes MLTC Nurse Care Manager Siew-Shing “Susie” Hwang, who checks in with Junior each month, and is available by phone whenever Junior has a question or a need for his mother. She also makes sure Luly keeps all her doctor’s appointments and that her medications are up to date. “If necessary, I can help schedule physician appointments and arrange for transportation,” Susie adds.

At the same time, as the health plan’s “eyes and ears” on the ground, Luly’s home health aides report any changes in her health, and this information is relayed to Susie. She will then let Junior and Luly’s primary care physician know.

As a result of this coordinated effort, “Luly has been very stable in her home—no falls, no hospital visits,” Susie says. “Without this level of care, she would have to be in a nursing home.”

The MLTC team also helps with Luly’s annual Medicaid recertification, which is necessary for continued enrollment in the VNS Health plan. “They’ve made it easy,” Junior says. “I’m pretty sure there’s more to getting recertified than I’m even aware of, but it’s been so well-handled by VNS Health.”

A visitor to the apartment can see the love between Luly and her care team, the hugs and kisses they exchange and the trust they share. “I love seeing her smile,” says Miriam. “It’s the greatest reward in the world.”

Speaking for Luly’s entire VNS Health team, Miriam adds, “I treat Luly the way I would like my own mother to be treated—with love and respect.”

* The patient and her family’s names have been changed for privacy.