A Smooth Transition Home from a Rehabilitation Facility

The Challenge:

Help Evelyn manage her father’s complex healthcare situation as well as his transfer from a short-term rehabilitation facility back to his own apartment in an assisted living facility.

The Caregivers:

More than 15 healthcare professionals in all, whose important contributions needed to be coordinated and documented.

The Solution:

A combination of education, coaching, meeting facilitation and customized healthcare tools.

The Result:

Evelyn has become an educated and empowered healthcare consumer and an assertive advocate for her father. He now lives in his own apartment, enjoys meals with friends, and participates in many activities.

Multiple Hospital Visits, Multiple Issues

Over a three-week period, Mr. B., age 89 and a diabetic, was in and out of the hospital three times and in the ER twice for a foot infection. Eventually, he was discharged to a short-term rehabilitation facility. Mr. B.’s situation was further complicated by multiple medical problems, including uncontrolled diabetes, possible renal failure and gastrointestinal upset from antibiotic therapy.

Throughout this process, Mr. B.’s adult daughter, Evelyn, was worried and confused. She assumed that many of her father’s medical issues were related, but was unclear as to how. Her chief concern: would her father ever be well enough to return home?

A New Facility and a New Health Care Team

Mr. B.’s move to a short-term rehabilitation facility meant that a new physician and nurse practitioner were overseeing his care. Evelyn had no prior relationship with this medical team and she was struggling to obtain clear, concise information about her Dad’s condition.

At this facility, Mr. B. was also receiving care from a physical therapist, an occupational therapist, a social worker, a speech pathologist, facility nurses and aids.  Evelyn discovered that this team did not always share information and coordinate care regarding his condition. Who was managing his diabetes?  Who was managing his foot care?  Who was addressing his GI upset and his reluctance to eat?  What were the goals of physical therapy? These were just a few of Evelyn’s many questions when she first contacted Healthassist.

Healthassist  is Brought in to Provide Professional Healthcare Consulting

Evelyn hired us to review her father’s medical records, sort out the interrelated issues, and relay this information to her in language she could understand. We then organized Mr. B.’s healthcare information and discussed strategies and an action plan to help Evelyn advocate for her father.

Specifically, we:

  • Formulated a list of issues to review with the short-term rehabilitation facility physician.
  • Facilitated meetings with all caregivers in the rehabilitation facility to discuss progress, set goals, and plan for discharge.
  • Collaborated with caregivers to identify community resources Mr. B. would need once he returned home, such as visiting nurse services, physical therapy and a pharmacy to prepackage his medications.
  • Set up personalized, online and offline tools to track Mr. B.’s medical issues and medications, blood sugars, weight, and food and fluid intake.
  • Educated Evelyn about her father’s healthcare issues and expected outcomes of interventions, and helped her formulate questions to ask his medical team.

Returning Home with Confidence

In a short amount of time, Mr. B was able to leave the short-term rehabilitation facility. With support, education and coaching from Healthassist, Evelyn helped her father be safe, healthy and happy in his own home.

Click here to listen to a Podcast on the subject of Skilled Nursing Facilities and Rehab