Patient receives the right care, at the right place and at the right time with WellMed’s CareCoach Connect

The program helps patients who frequently go to the hospital, helping them to find hope and live on their own terms

Denise Abreu has reconnected with her sister. She’s wearing jewelry. Her husband is getting a break. And she’s no longer in and out of the hospital, but at her home in Dallas.

These are big steps for Denise, who has multiple health conditions and has been largely housebound since a heart attack in 2022. Her transition was jump-started with visits from Dr. Barbara Onyia, WellMed associate medical director and a member of the CareCoach Connect team. Denise is one of 15,000 patients and counting who’ve been served by CareCoach Connect.

What is CareCoach Connect?

CareCoach Connect is a home-based multidisciplinary care delivery model leveraging WellMed’s integrated systems with a focus on meeting the needs of patients who are making frequent hospital or emergency room visits.

An interprofessional team, partnering with patients’ primary care clinicians, provides in-home medical care for patients who have a hard time meeting their healthcare needs. Providers can recommend patients to CareCoach Connect. CareCoach Connect partners with employed, contracted and affiliated clinicians in WellMed and Optum’s Texas and Florida markets.

Doctors, nurses, nurse practitioners, physician assistants, community health workers and social workers collaborate to provide the most comprehensive care for our patients in the comfort of their homes. They listen to patients and work with them to determine the best course of care.

“Conversations are about facing reality with compassion, giving patients the space to voice both their hopes and fears,” said Elizabeth Glazier, MD, MPH, Chief Medical Officer, Care in the Home, of which CareCoach Connect is a part. “It’s about equipping patients with the clarity and resources to live fully — on their own terms.”

From fear of dying to joy of living

Denise, a nanny, became homebound after suffering cardiac arrest on June 26, 2022.  With no other family nearby, Armando became her full-time caregiver. They struggled together.

Due to her frequent hospitalizations and declining health, Denise was identified by a WellMed hospital Case Manager in 2024 and referred to the CareCoach Connect team. Dr. Oniya made the first home visit to evaluate her and to develop a multidisciplinary plan of care to try to keep her at home.

Dr. Onyia and the team visited Denise at home at least three times a month for two months for both scheduled and urgent visits. The team spoke to Denise and Armando, her husband and caregiver, about her health, medications, illnesses and her goals of care.

During one of Dr. Onyia’s visits, Denise asked her “Am I dying?” She gripped the doctor’s hand. “I don’t want to die. I’m too young.” The conversation turned to the subject of hospice. They talked about how hospice care isn’t about dying. It’s about living. With her complex medical conditions, Dr. Oniya determined Denise was a great candidate for the Palliative Care program within CareCoach Connect.

“In medicine, some of the most transformative moments don’t happen in exam rooms during procedures,” Dr. Onyia said. “They happen in quiet, intentional conversations.”

Helping patients feel secure at home

Denise was struggling with 4.5 liters of oxygen. With hospice care she would receive 10. She also received medications for anxiety, pain and her chronic medical conditions delivered to her home, access to a 24/7 in-home care team and a home health aide to assist her with her daily needs.

For Denise, this would give her the security of being looked after. It could give her husband a break from caregiving. It also carried the promise of living her days on her own terms.

“Hospice shouldn’t be thought of as a last resort, but as a pathway to dignity, comfort and joy,” Dr. Onyia said.

What helped Denise become comfortable with hospice was the deep conversation between her and Dr. Onyia. “She listened,” Denise said.

Now Denise sees hope. Since starting with CareCoach Connect, she hasn’t needed to go to the ER or hospital. Instead, the CareCoach Connect team sees her in the comfort of her own home for all her acute and urgent needs. She has reconnected with her family. And for Armando, he can spend less time on caregiving and more time being a husband.

* To learn more about partnering opportunities with CareCoach Connect and/or to refer a patient, please call 877.521.6672.