{"id":90460,"date":"2026-05-15T08:52:14","date_gmt":"2026-05-15T14:52:14","guid":{"rendered":"https:\/\/www.uchealth.org\/today\/?p=90460"},"modified":"2026-05-15T10:18:22","modified_gmt":"2026-05-15T16:18:22","slug":"care-coordination-helps-patients-regain-stability","status":"publish","type":"post","link":"https:\/\/www.uchealth.org\/today\/care-coordination-helps-patients-regain-stability\/","title":{"rendered":"When grit wasn\u2019t enough, care coordination made all the difference"},"content":{"rendered":"
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\"UCHealth
UCHealth care manager Emily Everett, right, with her client, Ute Willmore. Ute receives extensive support from Emily thanks to a program called the UCHealth Medicaid Accountable Care Collaborative. Emily helps patients stay healthier and achieve long-term stability by connecting them with medical providers and community services. Photo by Joel Blocker, for UCHealth.<\/figcaption><\/figure>\n

The Fort Collins woman once worked as a software engineer and earned a good salary. She owned her home, loved skiing at Aspen and enjoyed road trips to explore natural areas across the U.S.<\/p>\n

Then Ute Willmore (whose name is pronounced \u201cooh-teh\u201d) faced health challenges that led to mounting instability, and eventually, homelessness.<\/p>\n

For decades, Willmore\u2019s \u201csalt of the earth\u201d German resilience carried her through life, from immigrating to the U.S. in 1979 and earning a college degree to building a successful career as a software engineer. She worked hard and valued her independence.<\/p>\n

But grit alone was not enough to stop a compounding crisis for this now 67-year-old woman. Chronic pain began to limit her ability to work. A job loss followed. Then the COVID-19 pandemic hit. As Willmore\u2019s health challenges grew more complex, navigating the healthcare system and unemployment became increasingly difficult. Eventually, the stability that Willmore worked so hard to build began unraveling.<\/p>\n

\"Ute
Ute is a former software engineer who enjoys knitting and crocheting practical items like socks, potholders and reusable grocery bags, filling her home with hand-made projects. Photo by Joel Blocker, for UCHealth.<\/figcaption><\/figure>\n

Willmore\u2019s path from achieving the American dream to homelessness is a stark reminder of how easily life can fall apart when health challenges and financial hardships overwhelm people. But her journey also shows how people can rebound from the toughest challenges. With support from dedicated community health workers who take a \u201cwhole person,\u201d approach, Willmore is stable again. She now has a place to live and can seek help from her UCHealth care manager whenever she\u2019s facing new challenges.<\/p>\n

Willmore rebounded thanks to a program designed to improve long-term health outcomes and reduce healthcare costs and by providing intensive, ongoing support to people with complex medical and mental health needs. Rather than relying on emergency services when challenges reach a breaking point, program participants receive consistent support from care managers.<\/p>\n

Health experts have learned that when barriers to care go unaddressed, people often delay treatment until their problems become so severe that they must rely on emergency services. This approach strains the healthcare system and results in big costs and complications for the entire community, while offering only a short-lived Band-Aid for underlying chronic conditions and psychosocial stressors. By stepping in to help patients earlier, care managers help people stay healthier and avoid expensive health emergencies.<\/p>\n

Willmore is a perfect example of how the program helps people succeed.<\/p>\n

One setback after another: How Willmore\u2019s problems compounded<\/strong><\/h2>\n

Willmore built a successful career in government contracting as a software engineer before moving to jobs in the private sector for several more years. She enjoyed the work, but long hours sitting at a desk began to take a toll. Over time, Willmore\u2019s lower back problems worsened, and she developed scoliosis and a bulging disc.<\/p>\n

She first sought help from her primary care doctor in early 2000s. Medications eased her symptoms at first, but as the years passed, Willmore needed larger doses of pain pills to function. Eventually, she was taking the highest dose of morphine that her insurance plan would cover.<\/p>\n

Then, everything else began to unravel.<\/p>\n

Her employer ran into economic problems and laid Willmore off. At age 60, she was not ready to stop working and began applying for new jobs. But age discrimination makes it tough to get a new job at age 60. Then, the COVID-19 pandemic shut down much of the economy, along with Willmore\u2019s chances of finding a job.<\/p>\n

\"Ute
Ute had to use a wheelchair while recovering from hip surgery. Coordinated care and community support helped ensure she had the help she needed while she recovered. Photo by Joel Blocker, for UCHealth.<\/figcaption><\/figure>\n

She applied for unemployment benefits immediately, but it took months before she got any payments. Her savings were already gone, and she began living on credit cards. Realizing this way of living was unmanageable, and with few options left, Willmore sold her home and moved into a room at a Motel 6. She managed the cost of the room for about a year, but money troubles forced her to leave and move into a friend\u2019s guest room.<\/p>\n

On top of losing her home, Willmore was dealing with agonizing pain. Her pain specialist had retired. With the opioid epidemic raging, Willmore struggled to find a new provider who was willing to prescribe the medications she now relied on to function.<\/p>\n

Managing her health became overwhelming, and the barriers in front of her felt insurmountable.<\/p>\n

During a call with a Medicaid representative, she was offered a lifeline if she would take it.<\/p>\n

Willmore agreed to a referral to what\u2019s known as the Medicaid Accountable Care Collaborative.<\/p>\n

\u201cThey asked me if I wanted an advocate. I said, \u2018Sure.\u2019 But I didn\u2019t really think anything would come of it,\u201d Willmore said. \u201cThen Emily called.\u201d<\/p>\n

\"For
For several years, Emily, left, has worked alongside Ute as part of UCHealth Medicaid Accountable Care Collaborative. The deep relationship between the women underscores how trust and consistent support can help patients thrive, even when they’re facing complex challenges. Photo by Joel Blocker, for UCHealth.<\/figcaption><\/figure>\n

How intensive help from a care manager and health coordinator changed Willmore\u2019s life<\/strong><\/h2>\n

Through the UCHealth Medicaid Accountable Care Collaborative, known as MACC, Willmore connected with a care manager named Emily Everett.<\/p>\n

Everett has a background in psychology and is a licensed professional counselor. She learned about MACC while working at a behavioral health center and providing crisis assessments in local emergency rooms. Everett made referrals to MACC from her prior job and was so impressed with the intense care management program that she soon applied for an open position and joined the team. That was six years ago.<\/p>\n

Her experience as a licensed professional counselor is foundational to her work as a MACC care manager. Her training in building connections and rapport as a precursor to change, growth and healing has become her core approach, she said. That relationship-first focus shapes how she does her work every day.<\/p>\n

The MACC provides community-based care management for high-risk, complex patients, like Willmore, who receive health insurance through Medicaid, the government-funded program for people who are disabled or who earn very little.<\/p>\n

Stephen Thompson manages care coordination for UCHealth\u2019s Community Health Improvement department in northern Colorado, and oversees three community-based care management programs:<\/p>\n