Maria (name changed to protect patient privacy) is a brilliant woman with a troubled health history. After a mental health diagnosis cut short her career as a high-level government official, Maria has struggled with diabetes, peripheral neuropathy, depression, and advanced kidney disease, leading to a series of toe amputations and a decade of disability.

She lives alone, about a half-hour from the nearest hospital, where she has been in and out of the complex wound clinic for more than eight years. After wounds in both of her heels took a bad turn, she spent time in the hospital followed by 30 days in a skilled nursing facility (SNF) — and 30 days only. Despite still needing significant care, being unable to walk on her own, and contracting COVID, her health plan called time on her coverage and sent her home — a crucial misstep that set her up for failure.

Because that’s where things got even tougher for Maria. Home health care should have been her next option, and it should have been arranged before her discharge. But even after calling a staggering 34 local agencies, her care team couldn’t find a provider able to meet her needs. Maria needed her bandages changed three times a week, and none of the agencies could take on the support she needed. They didn’t have the staff, they said, and were especially reluctant to work with Maria since she doesn’t have a caregiver at home who can learn how to perform the wound care recommended by her care team.

Instead, they suggested she should make the drive to the clinic three times a week to get her bandages taken care of. Transportation might have been available through a local agency, but there were no guarantees.

Unable to properly care for herself, Maria’s condition worsened. She was readmitted from the emergency department, the most costly location for patient care. Her care team was forced to discuss amputating both her lower extremities below the knee — a circumstance that would dramatically increase her likelihood of dying within the next five years.

Maria’s story is deeply tragic and should have been preventable. While standardized pathways and established protocols can adequately assist those in the bulk of the chronic disease bell curve, health plans simply cannot afford to limit themselves to one-size-fits-all services that do not account for socioeconomic complexities, poor transitions of care, and unaligned coverage decisions.

After all, the top 5 percent of medically complex patients, including those with concurrent socioeconomic barriers to care, incur approximately three-quarters of all home and hospital spending, as well as 50 percent of prescription drug costs.

Maria will likely be facing challenges related to this series of events for the rest of her life. But it’s not too late for health plans, particularly in the Medicare Advantage space, to take the right steps to avoid similar situations for thousands of other people like Maria who are at risk of falling through the cracks.

Provide enhanced care navigation for high-risk individuals during transitions.

Transitions of care are natural weak points in the chain of care coordination, often leading to medication errors, insufficient discharge instructions for patients, inadequate follow-up from providers — and $12 billion per year in potentially preventable spending on bounce-back admissions to the hospital.

Patients with complex health and socioeconomic needs, like Maria, suffer most from rocky transitions, with significantly reduced odds of completing follow-up when experiencing transportation issues or living alone.

Payors need to accelerate the use of predictive analytics and risk stratification tools to identify people at elevated risk of experiencing a gap in care or a preventable readmission. When flagged as high-risk, members should be paired with experienced, clinically informed care navigators who are dedicated to the member’s case across all care settings, including the home.

Care navigators should also be empowered to work with health systems, health plans, and community-based organizations to connect members with resources that proactively address socioeconomic barriers.

Develop flexible, personalized coverage determinations with a holistic mindset.

During her second return stay in the hospital (a 30-day readmission that likely cost her Medicare Advantage plan on their Star Ratings), Maria ended up spending 11 unnecessary, very costly days in the inpatient setting waiting on her next move.

This short-term thinking on coverage determinations is detrimental to patients while also jamming up the flow of care in the hospital setting. While it’s true that SNF beds are just as scarce in some communities, patients with extremely complex needs must have more options than simply being told to do their best at home.

Health plans should consider working with local health systems, SNFs, physicians, and home health agencies to better understand how members move through their care journeys and create a more flexible coverage decision tree with contingency options when a member presents with an out-of-the-ordinary situation.

Work with home health agencies to ensure the availability of resources.

Maria is among the 27 percent of seniors who live alone in the United States, which means her inability to secure home care due to the lack of a live-in caregiver is not an outlier. Instead of penalizing her for not having a caregiver available, she should have received extra attention from the dozens of home health agencies that turned her away.

Understaffing at home health agencies is a serious issue that cannot be solved by any single health care stakeholder. But health plans can do their part by contracting with high-quality, patient-focused agencies with a track record of success with complex chronic disease care. Actively choosing to work with agencies that can meet the needs of people living alone or with partners who do not have the capacity to provide adequate care will be essential as the population ages and the loneliness crisis deepens.

Maria experienced a perfect storm of failures from the entities that were supposed to provide care and support at a difficult time in her life. While she is currently recovering from her wounds and may be able to avoid extensive amputations, she is also exploring legal action against some of the stakeholders who let her down.

Health plans are in a uniquely powerful position to lead the way toward a more coordinated, person-centered, holistic chronic disease management environment. By working closely with SNFs, health systems, physicians, and home health agencies to close the gaps and create a community of care around complex patients, plans can make certain that patients like Maria are more likely to have better experiences and better outcomes.

Gary Marc Rothenberg is a podiatrist.