Services: Case Studies
A Smooth Transition Home from a Rehabilitation Facility
The Challenge:
Help E manage her father Mr. B’s complex healthcare situation and his transfer from a short-term rehabilitation facility back to his own apartment in an assisted living facility.
The Caregivers:
Over 15 healthcare professionals in all, whose important contributions needed to be coordinated and documented.
The Solution:
Customized, professional healthcare consulting that included education, coaching, meeting facilitation, customized healthcare tools and more.
The Result:
E became an educated and empowered healthcare consumer and an assertive advocate for her father. Mr. B now lives in his own apartment, enjoys meals with friends, and participates in many activities.
Multiple Hospital Visits, Multiple Issues
Mr. B, age 89 and a diabetic, was in and out of the hospital three times and in the ER twice in a three week period 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, which included uncontrolled diabetes, possible renal failure and gastrointestinal upset from antibiotic therapy.
Throughout this process, Mr. B’s adult daughter E was understandably 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 Means a New Healthcare Team
E enjoyed open communication with Mr. B’s primary care physician, but his move to the short-term rehabilitation facility meant that a new physician and nurse practitioner were overseeing his care. Because E had no prior relationship with this medical team, she was struggling to obtain clear, concise information on her Dad’s condition.
At this facility, Mr. B was also receiving care from a physical therapist, an occupational therapist, social worker, speech pathologist, facility nurses and aids. E discovered that this team did not always share information on 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 are just a few of E’s many questions when she first contacted Healthassist.
The Solution: Healthassist Professional Healthcare Consulting
E sought a professional healthcare consultant with a clinical/nursing background who could help her review her father’s medical record, understand the issues, and relay this information to her in language she could understand. Dianne Savastano, Principal of Healthassist, organized Mr. B’s healthcare information, discussed strategies and worked with E to develop an action plan to help her advocate for her father.
Healthassist Services Overview
Healthassist’s Dianne Savastano provided these customized services:
- Formulated a list of issues to review with the short-term rehabilitation facility physician
- Facilitated meetings of all the 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
- Created personalized online tools to track Mr. B’s medical issues and medications, blood sugars, weight, and food and fluid intake
- Educated E about her father’s healthcare issues, expected outcomes of interventions, and helped her formulate questions to ask
Returning Home with Confidence
After working with Healthassist, Mr. B was able to return to his home four weeks after he entered the short-term rehabilitation facility. With support, education and coaching from Healthassist, E helped her father be safe, healthy and happy in his own home.