It’s hard to stay healthy if you don’t have a place to call home.

That’s what we learned firsthand, when one of our patients came in for his annual wellness visit.

Thanks to Aledade, we’ve been doing a lot more of these AWVs. They give us a chance to have a conversation with our patients that’s not just about the test or procedure or illness they came in for that day. They help us see the full picture of the patient’s health. Thanks to Aledade’s care management trainings and real-time data and analytics from the Aledade app, we know which patients we need to see for an AWV, and how to work with them when they arrive.

Our patient that day was wheelchair bound, so we asked how his social situation was. Sometimes patients in a wheelchair can get to feeling a bit lonely. In the course of the conversation, though, this patient told us that he had recently lost his home. The waiting list for housing assistance stretched out for three years. In the meantime, the only place he could stay was a shed in his friend’s backyard.

As a care management team, we knew we had to do something.

Housing is such an important part of good health. The National Council on Health Care for the Homeless covers a few reasons for this. A clean, dry and safe environment supports good personal hygiene, the storage of medication, and safety from people and the weather. A private space lets a patient establish stable personal relationships, and have good social interactions with other people. Importantly for us as health care professionals, a patient with a place of their own is more likely to stick with a treatment plan, eat meals regularly, and show up on time for appointments. And housing reduces anxiety and the impact of stress-related illnesses.

Aledade’s practice transformation specialist Connie Perkins and I knew that a three-year wait was too long. So we spent countless hours on the phone with the state’s resources for homeless and disabled persons. Tooele is a rural community. We don’t have that many resources for housing, but after a lot of work and some persistence, we did it.

We were able to find housing for this patient in Wendover. Even though Wendover’s a two hour drive away from our town, the patient was thrilled to have a home of his own. He even started looking for work around his new place.

Thanks to an annual wellness visit – supported by the training, technology, and partnership of Aledade – we helped our patient get healthier, by finding a place to call his own.

Here at Aledade, we talk a lot about getting out beyond the four walls of the practice – because that’s how you get a window into the real challenges that a patient faces every day. They might be challenges we couldn’t have seen if we kept doing business the same old way. And sometimes, if we fix those, everything else can fall into place.

One of our partner practices proved this not too long ago. Dr. Syed Zaidi has been working in the town of Ripley, Tennessee for the past 20 years – providing care to the families around Ripley through his independent practice. And thanks to Aledade, he was able to care for them with some new tools.

In 2016, Dr. Zaidi started offering Chronic Care Management to some of his Medicare patients. This meant that a care management team would check up on his patients with more complex chronic conditions, making sure they had their medications and to try to get ahead of anything that could go wrong.

One patient had been in care management for a while, but Dr. Zaidi and his team weren’t seeing any changes. Neither he nor the patient felt like they were really making progress.

Then one day, the family opened up, and shared the real challenge they were living with every day. They were homeless. For several weeks, the entire family had been living out of their car – joined by a few animals they had adopted as pets. Their home had been infected with mold, making it uninhabitable, and they didn’t know where to turn.

That’s where the care management team and Dr. Zaidi’s whole practice jumped in. They helped the family find a safe place to live. Through community resources, they secured donations and raised money to provide the family everything from new mattresses to new clothes. And, since the family’s new home couldn’t take pets, Dr. Zaidi’s team even found good homes for every one of the animals. Today, the family’s healthier, and the patient’s chronic conditions are under much better control.

Chronic diseases are only going to get more challenging in the years to come. In 2012, the CDC estimated that one out of every two adults in the U.S. had at least one chronic condition. One in every four U.S. adults had two or more. And 86 percent of all of U.S. health care spending in 2010 was for people with at least one chronic medical condition. Chronic care management – by actually connecting patients with an active and engaged care management team – can tackle a daunting challenge for our health care system, and open up new possibilities in lowering costs.

But most of all, CCM helps our patients live better lives. Thanks to CCM through Aledade, we found out about this family’s situation. And thanks to the compassion and drive of Dr. Zaidi and his care management team, this family got back on their feet and back on the road to better health.