Coordinated care in action

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When it came time for 70-year-old Leon* to move from his home in Dracut to an independent living community in Brookline, the stakes were high. Leon is legally blind, an insulin-dependent diabetic, and had no family to help him with the move. One missed detail on move-in day could derail the entire transition. He was relying on his care team to make it happen.

But Leon had AgeSpan Geriatric Support Services Coordinator (GSSC) Kea Sar on his side. She worked with his team to coordinate a smooth transition to his new home. Kea has been Leon’ GSSC since 2022, when he became eligible as a member of the Tufts Health Plan Senior Care Options program. GSSCs act as a bridge between AgeSpan and the insurance company, coordinating services and acting as advocates for consumers.

Leon was approved by Tufts to have a companion aide accompany him on the day of his move, so Kea worked to secure one – taking the extra steps necessary to find an aide who spoke Haitian Creole, Leon’ first language. Recognizing that he would need help packing up the last few things in his apartment on the day of his move, she made sure the aide would be willing to help with these tasks.

“Kea coordinated across different teams for weeks to ensure no detail was missed,” Managed Care Program Manager Alicia Reppucci says. “She understood Leon was in a vulnerable position and put her experience and resourcefulness to work for him.”

Leading up to the move, she made multiple calls to confirm that a van would transport him and to find a Haitian Creole-speaking aide who would be willing to help with packing. Those extra touches made all the difference for Leon.

“Leon was very happy and thankful. It could not have gone smoother,” says Tufts Registered Nurse Case Manager Marnie Shambo.

Kea didn’t just trust that all would go according to plan. She went to Leon’ apartment on the morning of the move to make sure of it.

“When she pulled up, she noticed that the aide was walking around, searching for the right building,” Alicia says. “It’s a good thing she was there, because it’s very possible the aide might have been unable to find the right location.”

With nearly 11 years as a GSSC at AgeSpan, Kea has helped many older adults like Leon remain independent with the right blend of services and support.

“Words cannot express how grateful I am that Kea went above and beyond for Leon,” Marnie says. “She was a great partner and very reliable. What a rock star.”

* This name has been changed to protect the individual’s privacy