It happened every couple of weeks. When his hands and legs filled up with water, John Howey rushed to the emergency room.
"I'd keep on running into the same battle," he said.
It wasn't until medical workers with a new, innovative home health program for the most extreme chronic disease cases started daily check-ins that he got his symptoms under control.
He has edema, a symptom of his cirrhosis or late-stage liver scarring.
Before signing on with Geisinger at Home—the Danville-based health system's pilot solution for people who have complex, layered chronic illnesses—his hands swelled up and felt tight.
His edema put him at risk for other problems. He worried about a heart attack, and with good reason. He's had four of them, and four strokes.
He also has emphysema and chronic obstructive pulmonary disorder.
However, since Geisinger picked him among 2,500 other chronically ill patients across its network for the pilot program, a nurse now spots a potential problem from a command center and takes action.
He hasn't been back to the hospital since November.
The 100 or so nurses, physician assistants and social workers now running Geisinger at Home use technology to keep patients out of the emergency room and living better.
The program also employs roving doctors, dietitians, pharmacists and paramedics.
They're part of the changing face of health workers now steering patients away from hospital beds and collaborating to treat the whole patient as a team.
They're also part of the single fastest-growing jobs segment in Lackawanna, Luzerne and Wyoming counties. In the metro area, nearly 45,000 people work in health trades, and the sector has added 800 workers since January 2018, according to the latest state data.
Most talent acquisition officials will tell you they wish they could hire more, but, like every other industry facing bottom-of-the-barrel unemployment, qualified workers are hard to find.
Health administrators are stretching old recruitment techniques and adding new ones.
For the first time last year, Allied Services Integrated Health System started working directly with high school guidance counselors, in addition to the high school career fairs they already hold.
They're targeting high school seniors who haven't settled on career paths.
Counselors arranged for the students who hadn't committed to a college to meet with them, said Judy Oprisko, Allied's vice president of human resources.
For organizations like Allied and Geisinger, the employment crunch strikes particularly deep because they rely on workers across broad sectors, for example maintenance and information technology, housekeeping and security. All those job descriptions give workers a chance to climb the ladder and earn more money within the health system.
"Even food service could be a career path," Oprisko said, pointing out how staff at Allied's Skilled Nursing Facility in Scranton prepare more than 1,000 meals each day.
In March, Allied raised the starting rate for certified nurse aides at the Skilled Nursing Facility by $2 to $15 per hour with shift differentials for night and weekend work.
The health system leans heavily on nurse aides, who work in one of the lowest paying medical positions industry-wide. It requires the least amount of training, yet can be some of the most demanding work.
"You're lifting them in and out of the bed, you're showering them ... running around answering call bells," said Theresa Snyder, Allied's employment manager.
"For us, the struggle is the nurse aides," she said, adding that her fellow recruiters at other skilled nursing and rehabilitation facilities tell her they're up against the same hiring challenges.
"I know it's not just us," she said.
The health system, Lackawanna County's largest single employer, has its own in-house training program for nurse aide certification as well as signing bonuses and flexible work hours.
The health system offers tuition assistance, up to $3,000 a year, scholarships and loan repayment programs for employees who seek advanced training. Allied plans a high school career fair from 1 to 7 p.m. April 10
in the community room on its Morgan Highway campus. Students and parents can call 570-348-1348 for information.
Even if they have the right people to do the job, hospital advocates say bureaucratic red tape prevents qualified workers from reaching their full potential.
In testimony March 12 before the state House health committee, the Hospital and Healthsystem Association of Pennsylvania encouraged the legislature to act on bills that would give advanced practice professionals, including physician assistants and registered nurses who have advanced training, more freedom to treat patients without a physician's supervision and speed up the process in which insurance companies credential health providers within their networks.
Both initiatives, the HAP says, would increase patient access to providers.
Visiting with John Howey in his airy, lightly furnished apartment one cold March morning, Danielle Menichelli, a nurse practitioner from Pittston, flipped open her laptop.
She's the health professional who enrolled Howey in the program, though nowadays any number of workers might stop by depending on what he needs.
Geisinger identified around 10,000 patients across its network who are eligible for Geisinger at Home. Among the thousands already enrolled, the health system has seen up to a 45-percent drop in emergency room and hospital admissions.
A doctor visited Howey. A mobile X-Ray team set up their gear in his bedroom to take images.
Every day, he climbs onto a high-tech scale. The device, which communicates with a command center, sends his weight to a nurse who can tell right away if he's retaining water.
If that's the case, the nurse might call with instructions to take a pill.
If it's worse, the nurse can schedule a home visit.
Though it's not the case for Howey, some patients are bedridden, and wait until their conditions demand emergency help, said Janet Tomcavage, Geisinger's chief population health officer.
Home health workers become detectives who study patients' home environments to uncover conditions that worsen symptoms.
In one example, visiting health workers for a patient who frequently was hospitalized for lung disease realized she had no air conditioning.
Her home got unbearably hot and humid in the summer months, so they tapped a Geisinger community fund and installed a small air conditioner.
"She's had no more emergency room visits," Tomcavage said.
At Howey's kitchen table, he and Menichelli looked askance at two packs of Pall Mall cigarettes on the table.
If not for the home visits, Menichelli said Howey could hide the fact that he still smokes, something his doctors and nurses would definitely want to know.
"I'm trying to cut down, trying to quit," he said. "I don't like to smoke. It's a very hard thing to quit."