Case Study 1: Transitioning home from rehab or hospitalization
We got the call at three in the afternoon.
“Rehab called. Betty* gets released tomorrow morning at 11. We’re in Washington and can’t get there to help. Her doctor’s office told us about Cura for Care. How close to Brentwood are you?”
The nurse’s clipped voice betrayed her concern over the phone; this wasn’t just any senior needing assistance. This was her mother-in-law, and she needed a solution now.
*Details changed to protect privacy.
Betty and her husband were fine living far from their family—until she fell. Now, recovering from a fractured skull and broken pelvis, the local rehab facility had notified the family that Betty had to be gone by tomorrow morning.
From hundreds of miles away the family wasn’t able to help, but they had been told that Cura for Care has a reputation for reliable, high quality service with a commitment to timeliness, so they called us. “Please help us. We can’t leave her there.”
Our office called Betty’s husband, mid-80s, who said he wasn’t sure what kind of assistance Betty would require when she came home or if he’d be able to help her sufficiently.
We called the facility where Betty was scheduled to leave the next morning to determine her condition.
The rehab facility informed us that her insurance was done, so she had to leave by 11am. The “or else” fees were exorbitant. The family had to have her out or pay them, and they had hours to decide—from hundreds of miles away.
We asked the facility if she’d been released for discharge. Was she physically able to leave rehab?
They said they would have to do an assessment.
“Well, can she walk a hundred feet? Can she shower?”
They would let us know after the assessment.
We got permission to speak to a nurse who wasn’t confident she’d be safe coming home, so we went to her house to meet her husband Dave. We performed an assessment of the house and noted that it was fairly safe if proper help were available.
The nurse from the facility called us back and said that she believed with appropriate care, Betty would be safe to come home, as long as she had a walker, wheel chair, & bed side commode that could fit over the toilet for once she was up and walking.
We spoke to discharge staff at the rehab facility and agreed we would loan her this client equipment until the rehab center had the opportunity to order and deliver the required home safety aides.
Our staff went to the facility, performed an assessment, and agreed to move her now that we were satisfied it was safe for her to leave. Since no one from the facility was available to assist, we packed her belongings for her move home.
Before we allowed her to check out, we made it a point to get her discharge papers and get her home health nurse and therapy visits scheduled. We also made sure the facility went ahead and ordered her medications rather that waiting for it to get done "in a few days."
Once everything was in order, we transported her home where our Cura nurse aide was waiting. When we got her inside and comfortable, we reviewed her medications with them, got the house in order the way she liked it, made sure there were meals, got the sleeping accommodations arranged, set up a bedside commode, helped them order a walker and loaned them a transport wheelchair, and our care partner stayed with them until evening.
The next morning, our care partner returned and checked in with them at 8:30. Betty was still sleeping well, so she left and returned later in the day to help with hygiene, meals, and establishing a routine.
The next day, the nurse aide returned and helped her shower, organize the house, confirmed her appointments with rehab, and continued helping her settle in. The visits dropped to three days a week, then two days a week, and service continues to be needed less until eventually it will stop altogether.
This case study highlights the importance of an advocate when you or a loved one is being released from rehab.
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