Macon County’s Community Care Program once managed no more than 15 patients at a time. Today it handles more than 90, all free of charge.
The Macon County EMS Community Care Program assists at-risk patients through the county, monitoring frequent 911 callers and doctor referrals to help patients understand their conditions and how to take medications, as well as point them in the right direction for extra assistance. Program coordinator Joey Gibson said he often makes house calls to check on patients and keep track of those going to the hospital to prevent a repeat visit.
“We focus on everything from general medical problems to post overdose follow-ups to mental health crises,” Gibson said. “We try to only get involved to keep the people from going back to the hospital.”
This can include visiting a home where a senior may be at risk of falling to check on common trip hazards, or it can be as simple as connecting someone without food to services to keep them fed. Gibson said food insecurity can be a driver for poor health, with poorer individuals prioritizing rent or medical payments over nutrition. Older adults may struggle to prepare food or have limited access to nutritious meals.
The program also seeks to respond to mental health crises and overdoses. Gibson said a shortage of mental health providers can make it difficult to access care during a crisis. Waits for mental health care of any kind can be weeks to months. For seniors relying on government assistance, mental healthcare can easily take half a year to access, during which time they may be fighting through particularly dark times. Gibson helps these people to access care by pointing them in the right direction for doctors or other services.
“With our overdose program we want to try to help those individuals within 24 to 48 hours of their overdose, because that’s kind of when we found out that they’re most willing to accept help,” Gibson said. “Luckily, here lately, EMS is not getting called to as many overdoses in our county. That number’s kind of down a little bit, which is a good thing – but also overdoses are still happening and we’re just not getting called.”
The program maintains connections with No Wrong Door, Appalachian Community Services and various other doctors and nonprofits to help ensure healthcare is accessible to those who need it most, whether that means affordable medications or getting a prescription.
Speaking of Appalachian Community Services, Gibson said, “The past two times I’ve called with a crisis, it’s been less than an hour that I’ve had a worker to the house … We had a woman this week, lost her Medicaid, fighting a battle, couldn’t get her medications. I ended up going out to the home and then the mobile crisis worker was there … it was a phenomenal experience.”
“Basically, what I do is really aim to connect the dots,” he continued. “I’m not a licensed clinician, I’m not a substance use counselor, I’m not any of that stuff. What I have to do is just keep those resources in my head to know where to find these people … I’m thankful for what I get to do.”
The program was launched with limited resources in 2015, only two to three times per week with a cap of 15 patients, according to Gibson. The goal was to make a proactive effort to alleviate some of the problems of the most frequent 911 callers, saving lives – and the county time and money – by solving problems before they start.
Since then, the program has expanded, and Gibson now works as a full-time community care coordinator, aided by two to three part-timers who help respond to more remote locations in the county. He currently monitors 92 patients and tries to keep from adding more than 95. Sometimes he said he has to focus on the patients with the greatest need and then add more once others are out of the woods.
If possible, Gibson said he’d like to add telehealth services to the list of resources he can recommend, to make it easier for patients to get simple prescriptions without needing to wait for a doctor’s schedule to open up. He also wants to see more doctors in the area to help care for Macon County’s aging population.
“Thank you for the support of hospital, all the services in the community. It’s always good to have people to call for fresh support,” Gibson said.