CASE STUDY: Transitioning a client back to her home environment
THE SITUATION: Sylvia G., an elderly Florida woman, had been transferred from the hospital to a nursing home, where she then lived for two years at a monthly cost of $8,000.
Sylvia wanted to return to her own home, but the facility staff said she was too ill to leave the nursing home. At that point, the woman’s daughter, an attorney in Philadelphia, contacted Brown’s RN’s & Geriatric Care Coordinators, Inc. to evaluate her mother’s condition and determine if she would be able to successfully transition from the nursing home back to her own residence, and, if that were possible, to establish a care plan for her to address her needs.
MY ACTION PLAN
We conducted a thorough geriatric assessment of Sylvia, reviewed her medical chart, and interviewed the nursing home personnel. We then discussed her condition and prognosis with her health care providers, which included her primary and psychiatrist, asking for their opinion of her transfer back to her home and then, when they agreed, for orders for her home care.
At the time, Sylvia had 24-hour private aides, was confined to a wheelchair and was taking at least 30 different medications on a daily basis. She had multiple medical diagnoses — some of which were life threatening — and documented mental issues.
Sylvia was also under the care of 12 different medical specialists. However, because she had not had an RN/care manager accompanying her to her medical appointments, there had been no one to update the health providers regarding her medication list, symptoms, drug reactions and other health conditions. Once we took charge of coordinating her care and medication dosages with her physicians, we were able to reduce the number of sedating drugs she was taking with her doctor’s approvals, thereby diminishing her irritability and delirium.
We also visited Sylvia’s home, and assessed it to determine if any changes or renovations would be needed to accommodate her conditions should she return there.
After a thorough analysis of all issues relating to changing Sylvia’s living arrangements, we determined that, if needed modification were made in the house and support personnel were engaged to provide needed services, it would be possible for Sylvia to safely return to her home.
We discussed our findings with both Sylvia and her daughter, who agreed with our recommendations and plan of action. We then ensured the home was modified for wheelchair access, ordered necessary medical equipment, hired home-care attendants, and acted as a ongoing coordinator and mediator to address any in-home issues.
Two years have elapsed and Sylvia is still in her own home getting the care she needs. Both she and her daughter are pleased with the outcome.
CASE STUDY: Identifying a client’s medical condition
THE SITUATION: During one of our weekly visits to a client residing in an Assisted Living Facility, We noticed that there were indications that she had been suffering mini-strokes. Having been supervising her care for two years, we recognized the small changes in her condition, which, thanks to our geriatric nursing experience, alerted us to the problem.
MY ACTION PLAN
We notified staff members who conducted their own assessment and then refused to follow our recommendation to have her hospitalized immediately. Against their wishes, we called 911 and had her transported to the hospital, where, after a thorough examination, it was determined that she was indeed having mini-strokes. According to the doctor on staff, had she not been brought to the facility, she could have had a major stroke or worse.
Our client remained in the hospital for 10 days.. As a result of our weekly visits and monitoring of her condition, we were able to identify issues and take needed action to prevent problems from escalating and potentially becoming untreatable. This has greatly improved both her health condition and her overall quality of life.