A Tale of Two Patients

Mrs. Ellsworth

Mrs. Ellsworth is 86 and lives alone in Florida. Her only living relative, a niece, Becky, lives in New York. As far as Becky was concerned, her aunt was doing fine, living in an independent living community. Then came the call that Mrs. E had been hospitalized, having fallen in her apartment and found a day later, seriously dehydrated with multiple abrasions that needed wound care. Mrs. E had a history of hypertension, some thyroid problems, and had now been diagnosed with congestive heart failure. In the hospital, she was somewhat confused, but it was assumed that this was secondary to all she had been through. The plan was to discharge her with home healthcare from a certified Medicare agency. They would provide a nursing visit for the wound care, and some home health aide services for shopping and bathing a few hours a week for several weeks. As she had been independent prior to hospitalization, this seemed like a reasonable plan. Mrs. E was sent home on a Friday, and the nurse came Sunday afternoon, only to find her in her hospital gown, dehydrated, with no food in the house, and delirious from a UTI. Mrs. E returned to the ER and was readmitted. During her hospitalization she developed an infection requiring another 5-day stay and ultimately a transition for one month to sub acute rehab, and was then discharged with 24-hour home care.

Mrs. Thompson

Mrs. Thompson, 83, lives in Boston. Her daughter lives an hour away and has a high-powered, demanding job. Mrs. T was diabetic and noncompliant with diet. Her blood sugar skyrocketed; she became dehydrated, lethargic, and had to be hospitalized. They were able to bring all her levels under control in the hospital, and provided nutritional counseling. She was discharged, and the discharge planner arranged nursing visits from a Medicare-certified home care company a few hours a week for several weeks to make sure she was following her discharge regimen. The daughter thought that it would take more to be sure that her mother really would follow the recommendations and called SeniorBridge. Our nurse reviewed the recommendations and took the patient home. When they arrived, another member of the SB care management team was already there, reviewing meds and food, isolating the cookies, candy, and high-sodium foods and shopping for food based on nutritional recommendations. Mrs. T was introduced to a caregiver who had been oriented to all her needs. Soiled linens had been changed, the apartment was ready, and meals were healthy and freshly prepared. The SB caregiver came initially for 6 hours a day to ensure she was following her diet and eating properly. The Medicare agency’s caregiver provided 2 hours of assistance 3 times a week for grocery shopping. SeniorBridge’s services were wrapped around the Medicare agency’s. Mrs. T’s blood sugar remained under control, and after a month, the Medicare caregiver pulled out, but our caregiver remained for 4 hours 5 days a week. Our care manager goes in weekly to check her blood levels and diet, and she is doing great.

It's a far, far better thing we do...