Helping a Client Transition from Long-Term Care Back Home

The Challenge:

Help Mrs. R., a 95-year-old woman who was receiving long-term care at a Massachusetts nursing and rehabilitation center, return to her own home.

The Caregivers:

More than 20 in total, including family members and healthcare, legal and financial professionals. Their important contributions needed to be coordinated and documented.

The Solution:

A combination of coaching, meeting facilitation, team communication and attendance at medical appointments.

The Result:

With time, planning and consistent management, Mrs. R. was able to return home and live comfortably.

The Challenge of Living Alone

At the age of 95, Mrs. R. was hospitalized to treat shingles/herpes zoster. Until that point, she had lived alone in her home. Her closest family were two nephews who lived out of state; a local Visiting Nurse agency supplied a home health aide several times a week to assist with her personal care.

Following surgery seven years earlier for spinal stenosis, Mrs. R. became dependent upon a wheelchair and a Foley catheter. She lived on the first floor of her home which had been modified to include a wheelchair ramp and a first floor dining room converted to a bedroom. Although she spent most of her day in a wheelchair, she was able to walk short distances using a walker. Despite the fact that Mrs. R. had her groceries delivered and cooked for herself, upon admission to the hospital her nutritional status was depleted and may have contributed to her illness.

Transfer to Long-Term Care

After her hospital stay Mrs. R. was transferred to a nursing and rehabilitation center for a course of short-term rehabilitation that included physical and occupational therapy, all covered by Medicare. She now required more services on a daily basis than she had in the past and became a full-time, long-term resident of this facility.

Her wish was to return home but no one was able to oversee and coordinate this move. Her friends and family assumed she would stay at the long-term care facility for the duration of her life. 

Coordinating a Return Home

Soon after her admission to the long-term care facility, Mrs. R. retained the services of an Elder Law Attorney to assist her with legal and financial matters. During her first meeting with the attorney, Mrs. R. defined her goals:

  • To return home to live
  • To walk more often

To fulfill her wishes, the attorney knew that Mrs. R. needed coordinated care from a team of providers as well as someone to oversee these services consistently. He introduced Mrs. R. to the team at Healthassist.

The Solution: Healthassist  Professional Healthcare Consulting

First, Healthassist set up a meeting with Mrs. R.’s long-term care facility team: the physician, the nursing director, the director of rehabilitation and the social worker. They determined that Mrs. R. had no acute medical issues that would prevent her from returning home. They were eager to assist with the transition – provided it was effectively managed.

Next, Healthassist consulted with a local primary care physician whose practice specialized in the care of elderly individuals. The physician, who was certified in Geriatric Medicine, partnered with Mrs. R. and Healthassist to care for her in her community.

Finally, and to ensure a successful transition home, Healthassist recommended that Mrs. R. hire a private, 24×7 live-in caregiver. Further, and to help Mrs. R. meet her goals of improved walking and other functional abilities, Healthassist connected her with a private physical therapist to supplement any PT services Mrs. R. might receive at home from the Visiting Nurse agency.

Through the transition process, Healthassist :

  • Provided clear, concise communication to all Mrs. R.’s caregivers, including the local Visiting Nurse agency
  • Facilitated the hiring of a 24×7 live-in caregiver
  • Arranged for nursing visits to pre-fill Mrs. R.’s medications
  • Conducted a home assessment and coordinated the services to make Mrs. R.’s home safe and convenient for the transition
  • Connected Mrs. R. to a private physical therapist to help her maintain and improve her walking skills

On an ongoing basis, Healthassist :

  • Coordinates all medical care and attends all physician appointments with Mrs. R.
  • Facilitates communication among 20 individuals, including medical personnel, caregivers, family members, friends, neighbors, and legal and financial services professionals
  • Helps Mrs. R. manage acute medical issues and temporary hospitalizations

Back to the Home She Loves

Today, Mrs. R. lives happily in her home, surrounded by her books and cherished personal items, enjoying a view of the ocean from her own back yard.

Click here to listen to a 30-minute interview with Stephen Spano, elder law attorney.