When he was a little boy, Tony Bell’s grandmother called him Mister Independence “because I always wanted to do things on my own.”

But his independence was slipping away as he struggled with heart failure — and his challenge was growing ever more difficult.

He could no longer climb stairs and had to relocate from his third-floor apartment to a unit on the ground floor. He had to rely on his niece to go to the bank and shop for him.

“Carrying the trash from my apartment to the dumpster was an all-day job,” he said.

In 2016, he was hospitalized three times, eroding his independence even more. He got back on the right track through Carelink CareNow, a program powered by Christiana Care Health System that connects patients with extra help so they can lead the healthiest, most productive lives possible.

Carelink CareNow’s innovative model mines electronic health records, claims data and real-time data feeds from two powerful regional data repositories — the Delaware Health Information Network and Chesapeake Regional Information Program — to identify populations that are most at-risk and intervene to avoid unnecessary and costly Emergency Department visits, hospitalizations or skilled nursing care. The team includes doctors, pharmacists, nurse care coordinators and social workers.

Bell, 62, has had serious health issues for much of his adult life. He was on dialysis for 10 years before undergoing a successful kidney transplant in 2010. He was able to return to work for nearly five years before he developed unrelated heart failure.

Brenda Walsh, MBA, MSN, RN-BC, a Carelink CareNow coordinator, calls him at his home in Wilmington on a regular basis as part of a program that assists heart failure patients for 90 days after hospitalization.

“We make sure he keeps his appointments and that his test results are reviewed with the doctor,” she says. “Tony and I review his medications and talk about his menus to make sure he is avoiding salt.”

Walsh also coordinated his care with a Christiana Care visiting nurse who saw him twice a week for 60 days.

“The visiting nurse got me from not even climbing a step to climbing two flights of stairs,” he said.

Soon, he was walking longer distances and lifting weights. He resumed activities he enjoys, going to church, cooking meals, shopping at the home improvement store and going to the bank.

He also has made strides in monitoring his weight, which is essential in helping keep heart failure patients on the right track.

“I had been keeping fluid in my legs from drinking more water than I should,” he says. “Now that I am keeping my weight where it should be, I am doing real well.”

As an active partner with the Carelink CareNow team, Bell is leading a healthier, happier, more independent life.

“Tony is very good about taking care of himself and he has his niece to help him,” Walsh says. “All he needed was us to give him reminders, reassurance, and resources when he needs them.”