Case Study 2

Marsha* and her family asked me to intervene and provide assistance on her behalf and to help her return to her home and live independently.

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*Not her real name

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Marsha was in a very nice assisted living with expansive facilities and an impressive rehab center. She asked if I come visit her and start arranging plans for her discharge home.

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I went to visit Marsha. She told me she hadn't done any exercises now for two days, that she had no insights as to her discharge plans, and she was just sitting in bed with no assistance or feedback.

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I spoke with the nursing staff at the nurse desk, and they confirmed that since her arrival, they hadn't received a physical therapy assessment on Marsha, and they couldn't help her with any exercises. I pointed out that she had been at the facility for two days.

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They said they would get to her.

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I then went to the physical therapy senior staff and asked them when they could have an assessment, and they told me they needed a nurse order, but that she was on the list and they would get to it in the next day or two.

 

I pointed out again that she had been two days in the facility with no exercise and no physical therapy. They mentioned that the nursing staff should be able to help her walk and do her exercises.

 

I returned to the nursing staff who said that they did not have orders from the head nurse.

 

I checked with the head nurse who by now saw me as a nuisance. Eventually she declared that Marsha didn't need one of the CNAs to help her with walking twice a day because that hadn't been put into the care plan yet.

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While I was sitting there, I asked her if she could please put it in the care plan. She agreed and added it to Marsha's care plan.

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That same day, I went to the nursing desk and asked the staff if they were going to be able to walk her today. They looked in the care plan and said, "Oh yes, we can do that twice a day."

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When I asked about exercise, they said they couldn't do that until the physical therapy assessment was complete. I went back to the head nurse and asked her if she could please put in the urgent request for a physical therapy assessment because Marsha had been there for several days with no assistance.

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The head nurse agreed and walked with me to the physical therapy room where we talked to the physical therapist and asked them if they could complete the assessment today. They said they would complete it the next day.

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The next day, I called the physical therapy department and they agreed that they would complete her assessment ASAP.

 

That afternoon, I stopped in and sure enough, they had completed the assessment for Marsha and gave her clearance to be able to walk two times a day and start her physical therapy at once.

 

Checking with Marsha, she mentioned that she had not walked now in three or four days that she had been there. So Marsha and I took a walkaround the facility, and the CNA on staff came up and asked what we were doing. I told them we had clearance from the physical therapy department and that she was to be walking two or three times a day. And since they had not gotten to it, we had decided to attempt it on our own.

 

The nurse aid said she would put it on her list, and immediately they started walking with Marsha two or three times a day and started her physical therapy.

 

As with all rehab facilities, they had planned to keep Marsha for three weeks to maximize the insurance payment. We spoke with the discharge person who said that they would be keeping her for three weeks, and Marsha said she was ready to get out of there sooner and started making request to be able to discharge earlier.

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The physical therapy department was notified, as was her head nurse, stating that Marsha wanted to go home sooner rather than later. We made arrangements to prepare Marsha's home for her return.

 

A few days later, Marsha had regained her strength and was able to walk to all ends of the facilities on her own, using the stroller just as an additional security aid. The physical therapy department cleared her to go home, and the nurse agreed as well.

 

The next challenge was to address the medications that she was on as her home medications had been changed by the hospital, and then the hospital medications were changed by the rehab center. This again required a meeting with the head nurse who went through the medications with us and streamlined them so that she would have clear medications to take home.

 

We contacted our pharmacy which does dose packaging. They reviewed the prescriptions, cleared it with Marsha's doctor, and agreed to provide those medications for a week.

 

We then set up an appointment with her doctor for a day following her return home. When the day finally came, we had a certified nurse aid with us, and we took her home. We put everything she needed in the refrigerator, made sure her house was clean, and saw she had everything she needed.

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We prepared her meals and her bed and Marsha spent the night. The next day, we picked her up and took her for her appointment with our regular doctor who reviewed all the medications. Marsha is a diabetic and needed special medication, and the doctor made the accommodations.

 

That same day, he phoned in the prescriptions to the pharmacy which provides dose packaging, who agreed to get the medications in the next day. The next day, we picked up the dose package medications, took them to Marsha, who was a bit confused about how to use the dose packaging.

 

We transferred the medications into a medicine tray and agreed to have a care partner there in the morning and in the evening to help her take her medications as well as do her exercises.

 

Marsha was anxious to get out of the house, so we decided part of her exercise routine would be to go to the store with one of our care partners. This was in alignment with the prescription from the physical therapist.

 

Marsha loved getting out of the house doing her shopping. They would come home, do some cooking, do some more exercises, make sure she had her medications in the morning and in the evening, and have a nice night's sleep until the next day when we would do the same things all over again.

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Marsha's family was very much in touch and agreed to all the plans and was involved in the medications and updated on the conversations with her doctor. Three weeks later, Marsha was feeling strong, and we decided she did not need daily care, and we reduced the care to every other day, four days a week.

 

We have since adjusted her medications again with her doctor's approval, completed the dose packaging for her, and we put it in the MedTree on a weekly basis. Our staff checks in on her three days a week to make sure she's taking her medication.

 

We also take her shopping and outings and make sure her groceries are caught up and that she has meals to eat. Marsha has resumed her social life, participating in a reading group and other activities with her friends. She also spends quite a bit of time on the phone talking with family and friends.

 

Frequently, the three-hour or four-hour daily visit from our care partner turns into a longer visit as Marsha wants to go shopping and go to stores and to dinner, and we are happy to transport her.

 

There had been some water damage to Marsha's house, and her car had been hit while it was in the parking lot. We helped her through each of these challenges.