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Feature Story:

Reclaiming lives is a team effort


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Nurse and patient smiling at each other

Reclaiming lives is a team effort

For Carolyn Gover, life had become a series of overwhelming challenges. In January 2015, her husband died suddenly. Soon after, she was diagnosed with breast cancer. Then she fell and broke her hip. “It was one nightmare after another,” said Gover, 76, a retired psychologist. Her financial health suffered, too. She was about to lose her home in Rehoboth Beach to foreclosure. “I had to find another place to live.”

Gover couldn’t handle things on her own. She received help when her needs were identified by ChristianaCare’s care coordination community team — doctors, pharmacists, nurse care coordinators and social workers who focus on eligible patients who have complex behavioral, medical and social health issues and are in the top 1–5 percent of risk.

“Most of the drivers of the quality of health are social factors,” said Diane Bohner, M.D., medical director of the team. “Someone can’t sleep because he doesn’t have a bed. Someone doesn’t go to the doctor because she doesn’t have transportation.”